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“There is no such thing as a drug-free society.  Are drugs becoming the norm?

Claude Faugeron and Michel Kokoreff


            For many years, drug issues were shaped by prohibitionism and perceived links between the fringe elements of society, heroin and exclusion, but now, at the dawn of the 21st century, they seem to be part of a new landscape both in France and in other major countries in Europe.  Of course, things did not change completely overnight.  However, we are seeing new problems and categories that are causing us to question the ideal of a drug-free society.  Ultimately, that line of thinking leads to the notion of societies with drugs. This change in norm is taking place against a backdrop of new risk reduction policies and is reflected in a tangible way in two types of phenomena: new forms of social use and self-regulation, and the activation of existing prevention and support mechanisms and the introduction of new players (self-help groups, “front-line” workers, mediators, etc.).  None the less, approaches to intervention are still difficult to reconcile.  Strong institutional approaches (criminal law, health) stand in contrast to approaches that are far less certain or that entail grey areas when it comes to establishing new mechanisms.

            This is the context in which this paper was compiled.  The aim is to get a better grasp of the array of forms of drug use and at the same time clarify changes in and the impacts of public policy.

 

 

 

I. Shift in drug policy in France

France’s drug policy has changed since the mid-1990s.  The changes resulted from greater awareness of public health problems related to the use of illegal drugs, the realization that there was no way to eradicate substance abuse and pressure from neighbouring countries.  France could no longer go it alone.[1]

The change in public health began with the suspension of the 1972 order making it mandatory to produce identification when purchasing a syringe at a pharmacy.  Needle exchange programs and the sale of sterile kits developed in the early 1990s.[2]  A milestone in the middle of the decade was the February 1995 release of the Henrion Report,[3] which recommended quick development of a risk reduction policy.  The report won support from a number of authorities: Comité Consultatif National d’Ethique (1994), Commission sociale de l’Episcopat (1997), Ligue des Droits de l’Homme (1996). The documents drew considerable media attention, sparking a public debate on risk reduction.  Methadone and high-dosage buprenorphine (Subutex®) received marketing approval in 1995.  The use of Subutex®, which is distributed by general practitioners with few administrative restrictions, for substitution treatment developed quickly, too quickly in some cases (Lert et al. 1998), while the distribution of methadone, which can be dispensed only by a specialized centre, is still not really widespread (Morel, 2001). According to Lert (2000), some 3,500 patients were being treated with methadone in July 1999, whereas an estimated 64,000 were taking Subutex®.

Finally, drug treatment professionals and workers stated in no uncertain terms at the national meetings on drug abuse and addiction in 1997 that they supported a risk reduction policy and even decriminalization of the use of illegal drugs.  Many called for the 1970 legislation to be repealed or at least amended.  Health secretary Bernard Kouchner gave a measured response: “I do not believe that a hasty debate will bring about the necessary changes to the legislation.  But it is important to proceed with caution and convince all of the players.  We can develop a new mindset nevertheless and take comfort in the fact that the debate does not become a farce.”  (p. 141).  Many players have indeed changed their way of thinking.  Specialized workers are no longer hostile toward substitution as they were for many years (Bergeron 1999).  The courts are increasingly reluctant to put people in jail for simply using drugs.  The ministry of the interior refuses to amend the legislation in any way, but some police officers are hesitant to write tickets and report to the public prosecutor’s office.  More and more, the public prosecutor opts for something other than an injunction ordering treatment.  The number of people being questioned by police in connection with simple drug use may be up, but the number of convictions is relatively unchanged; more importantly, the number of people incarcerated for a primary offence of drug use has fallen sharply (from 1,213 in 1993 to 471 in 1999).[4]

 

From the outside in

This account glosses over the deeper reasons that led to changes in French public policy on substance abuse.  Perhaps a good image would be movement from the outside in.  French Jacobean tradition, the evaluation practices established by the government (which is more interested in effects than processes) and a focus on public order issues make it difficult to see such movement.[5]  This is not a matter of local opposition to a central view, but rather observation of how very real problems that can arise in day-to-day living, such as finding used needles in public places, the unpleasant sight of beggars and small-time dealers, fear of AIDS spreading among populations not considered to be high risk, and lack of control in local facilities serving very poor populations, can mobilize local players and bring about an array of very different solutions.  Some solutions will be exclusionary: a ban on begging or relocation of street kids.[6] Others will try to mobilize the resources available under city policies (Joubert, 1998; Kokoreff, 1997).  Still others will endeavour to rationalize by casting the problem as a public health issue.

The public health argument is certainly one of the strongest available to those seeking a risk reduction policy.  As Fassin (1998) pointed out, in matters of public action, health has a legitimacy all its own, and in the area of drug abuse, close scrutiny of local situations shows the extent to which the actions of some professionals, associations and elected representatives have a truly innovative effect on public health (p. 16).

In many cases, the process begins with tinkering that is often difficult and may or may not be successful.  But that tinkering can lead to the creation of doctrine and the transfer of expertise.  The transition is also helped by the fact that political figures in France are often involved in municipal life and local communities.  Mayors, deputies and senators, particularly (but not only) those from the left, bring to the debate the experience gained in their municipalities.

Progress toward national public action is not immediate and requires a great deal of work to build doctrine and prepare joint representations; France still has a long way to go.  In his article, Ogien highlights the difficulty in trying to transform into a public health policy a public order policy that was dominant until the 1990s.  In the French system, there are two constraints that shape public action: do not impose measures that would be perceived as attacking individual freedoms; and do not break the monopoly physicians hold on medical expertise and decision making. To get around these constraints, the health ministry encourages initiatives by user groups[7] in order to allow better use of resources and prevent risks related to injection.  But in today’s political climate, the health ministry cannot easily afford to grant the requests now being made by groups lobbying for the decriminalization of drug use and the controlled distribution of heroin, just as the distribution of Subutex®  or clean needles can help improve the health of intravenous drug users.  This explains the tentative position taken by Bernard Kouchner in 1997 (supra) and the position taken in the years following by Mildt president Nicole Maestracci.

 

Producing knowledge

The late 1990s also shed more light on users of illegal drugs.  Until then, the only source of knowledge was the occasional epidemiological survey of small age cohorts and/or target populations, such as high-school students, or studies that by and large applied only to specific groups of users, most of them selected using the “snowball” method.  The lack of knowledge was lamented first by the Association Descartes program (Penser la drogue, penser les drogues, 1991) and later by the Padieu Report (1994).  It bears repeating that until the late 1980s, empirical studies of drug use and sale were few and far between (Ehrenberg, 1992).[8]  A number of studies conducted in the following decade helps offset this “knowledge deficit” (Faugeron, 1999; Faugeron, Kokoreff, 1999).  A series of studies, most of them qualitative and ethnographic, looked at the use and users of marijuana (Aquatias et al., 1997; Bouard, 1994; Ingold and Toussirt, 1998), heroin (Bouhnik, 1994; Bouhnik and Touzé, 1996; Toufik, 1997, etc.) and, to a lesser degree, synthetic drugs (Kokoreff, Mignon, 1994; Ingold, 1997; Inserm, 1998; Colombié, Lalam, Schiray, 2000; Médecins du Monde, 2000). There were no studies, however, on crack and cocaine apart from two ethnographic studies conducted in Paris (Ingold, 1992 and 1994). There were also studies that focused not on a particular substance, but on a particular type of territory (Joubert et al., 1995 and 1996; Duprez, Kokoreff, 2000) or specific groups (Hédibel, 1997; Tarrius, 1997; Pryen, 1999); these studies took a more horizontal approach to drug use and living conditions.  Ultimately, though – and we will come back to the subject of practices – these studies only scratch the surface of drug use.  Moreover, reliable statistics separate from those produced by institutions and studies of the general population have been scarce.

The lack of this type of data was the driving force behind the creation of the Observatoire français des drogues et des toxicomanies (OFDT).  In the years since, the OFDT and outside partners have conducted general population studies using more comprehensive methods.  Beck (2000) lists those studies and points out the methodological problems.[9]  There is no perfect study, regardless of the data collection or sampling methods used.  One of the most complicated hurdles is the small number of users of some substances, which makes it hard to extrapolate the data to the general population.  For that reason, the studies conducted in France apply at once to broad populations (12-75 years), such as the “Baromètre santé”, to populations considered more sensitive in terms of use, such as public- and private-school students, and to young people (17-19 years) called to defence readiness days.  This system is complemented by a system of observing recent trends (TREND) that does not provide specific figures, but rather information on patterns of use and emerging uses.  TREND[10] identifies two types of use: urban use, which is characterized more by “hard” use, and recreational use. Heroin use is declining in urban areas, although it is still the drug of choice.  Stimulants (ecstasy, cocaine and speed) are the most popular recreational drugs.  Stimulant use has increased among both hard and recreational users, as has the mixing of drugs, often to counterbalance the ill effects of coming down.  All these studies underscore the prevalence of multiple drug use, in particular one or sometimes two illegal substances (not necessarily at the same time) with misused medication and alcohol and tobacco.  The increase in tobacco use among young people is at least as much a concern for public authorities as the use of illegal drugs.

Some studies provide greater insight into changes in public opinion.  The 1999 study by the OFDT[11] showed that a large majority (80.8%) favoured using alternate substances and a smaller majority (63.0%) agreed that needles should be sold without a prescription.  Even controlled distribution of heroin is relatively acceptable (52.9%) (see Beck, Peretti-Watel 1999).  The authors note that comparison with previous studies indicates an upward trend in the acceptability of alternate substances: “[translation] Overall, public acceptance in France of initiatives related to the risk reduction policy seems to have been increasing since the early 1990s” (p. 133).  Opinion is divided as to whether illegal substances should be banned: 52% of the people surveyed think that a ban on marijuana would be ineffective; only 48% think the same for heroin.  On the whole, the people surveyed do not like the idea of marijuana legislation.  However, controls on access to marijuana drew support from about 30% of the respondents.  The overwhelming majority of respondents said care should be mandatory.

To some extent, these results are in line with the increasingly prevalent media portrayal of drugs as a public health problem.  That portrayal mitigates some of the adverse effects of the 1970 legislation with its two components aimed at eliminating use and placing users under medical care.[12] Those two components are in constant conflict, which professionals deplore, since police pressure counteracts efforts to establish risk prevention measures.  Although the absolute number has increased, injunctions ordering users into treatment have not had the desired effect; the evaluation by Setbon (2000) shows that enforcement varies dramatically from one jurisdiction to the next and that it is almost impossible to gauge the results.  Some jurists see the evolution of the 1970 legislation as “normative tinkering” and refer to the ineffectiveness, indeed the counterproductiveness, of the current legal framework (Charvet 2000, pp. 80 and 81).  With regard to orders of care at the trial or parole stage, Simmat-Durand (1998) showed that very few statistics were available: the number of treatment orders issued by youth judges, trial judges and other authorities was statistically negligible.  According to Simmat-Durand, this near-insignificant result showed that the mechanisms established in the 1970 legislation have not worked.  On the other hand, charges for use have increased considerably, from 24,588 in 1993 to 73,661 in 2000 for marijuana.  Charges for heroin use have fallen since 1995 (from 13,299 to 4,831 in 2000).[13] The police are essentially marijuana police.  Other undesirable effects include grappling between the police, the courts and public health officials that facilitates the sale of adulterated substances, which adversely effects users.

 

A less Manichean debate

The three-year plan to combat drugs and prevent addiction (MILDT 1999) is part of a grassroots movement and will use the public health argument.  To its credit, the plan recognizes that there is no such thing as a drug-free society, clarifies some concepts and affirms that addiction prevention and control pertain to more than just illegal drugs.  It also clearly illustrates the difficulty of reconciling repression and care and the failure by the courts to mobilize treatment mechanisms.  It points out that the existing system focuses too much on heroin users and does not tackle problems related to problematic use of other substances, whether legal or illegal.

The first clarification consists in dispelling the notion of drug addiction by recognizing the existence of risk-free use and focusing on problem use and dependency.  Challenging the very notion speaks volumes about the observed change, as illustrated by Bergeron: “[translation] Through most of the 1970s, the health ministry and some centres were convinced that drug abuse was a ‘solvable’ problem, a problem that affected only some young people who would ultimately be saved.”  (Bergeron, 1999, 198)  The increase in use and then the appearance of AIDS fuelled that belief.  Today, people still talk about drug addicts (both in the clinical sense and as a generic category), and even multiple drug addicts, but the fact remains that the notion of “drug user” has become commonplace in social discourse (among politicians, institutional players, professionals, journalists, etc.).  The distinction between use, abuse and dependency introduces a new shade of meaning: it not only indicates a shift from the substance to the behaviour, but also means that not all drug users are drug addicts” (Parquet et al., 1999).  Granted, these distinctions are simply a recapitulation of the distinction made by the WHO: use, harmful use (abuse) and dependency; however, they still serve to focus government policy on the prevention of drug use problems and the related risks.

But at the same time, the notion of prevention loses the narrow meaning it had been given in the 1970s and 1980s, that is, prevention of drug use, and now includes prevention of health and social damage for users and those around them.  This broadening of the concept of prevention is reflected in the slogan “know more, risk less” that appears on the small brochures published by the MILDT.

Extension of the anti-drug policy to include legal substances, primarily tobacco and alcohol, and the misuse of prescription drugs plays down dependency on illegal drugs in the broader context of studies on addictive behaviour and is an attempt to revitalize a sector of treatment that is in escheat, particularly with regard to alcohol.  The three-year plan also includes measures to strengthen alcohol counselling and bring it more in line with specialized care and to create a diploma program in addictology; that program turned out its first graduates in June 2001.

 

Inertia of institutional thinking

It is certainly too early to assess the impact on mechanisms and practices of this change in discourse and the measures accompanying it.

The circular on court responses to substance abuse (JUS 9900148 C, July 22, 1999) recommended that judges would be better to use existing mechanisms, in particular quick social surveys, analyses, reference to the law in the form of dismissal with a warning, dismissal with a referral to a health, social or professional facility, court-ordered socio-educational monitoring, suspended sentence with testing, general work, parole, etc.  Unlike its predecessors, it made a clear distinction between casual use, abuse and dependency.  It urged the courts to take into account users’ efforts to get involved in an integration process, to ensure continuity of care and to incarcerate users only as a last resort.  It reiterated the view that court-ordered treatment should be used wisely, only for heavy users of illegal substances. It reaffirmed the need for courts to deal with users locally, in liaison with the competent authorities, in particular the police and customs.

The most innovative measure is the “incitement to undergo care” outside the framework of court-ordered treatment.  It is reminiscent of the “praetorian probation”[14] used by Belgian judges and analysed in the paper by Christine Guillain and Claire Scohier.  What is different is that it cannot lead to dismissal with no further action; it must help shed light on the correctional court’s decision.

The thinking behind the circular is clear: avoid making casual users subject to severe measures out of scale with their offence and their social situation.  On the other hand, it is difficult to see why there would be a raft of measures that were largely unused in the past, as illustrated by Simmat-Durant (1998). Further, users are still at risk of being charged with possession of or trafficking in narcotics no matter how small a quantity they have.  In any event, we are compelled to discuss the operational thinking of the criminal system, so aptly described by Aubusson de Cavarlay (1997, 1999).  Based on an analysis of narcotics cases handled by the public prosecutor in Brussels over a five-year period, Guillain and Scohier showed in their paper that judges have not made extensive use of the new measures available to them.  They went on to say that the criminal system’s reaction is basically driven by socio-individual criteria, including the existence of a “record”, that is, a history of failed measures.  It should be added that socio-health and criminal mechanisms are not always compatible.  Urging judges to rely on the expertise of social work and health care creates a grey area between the two which the vague phrase “reference to the law” does not manage to clarify.  The youth justice system has long had and still has to deal with this problem

The problem is complicated by the recurrence of concerns about safety.  The message is aimed first and foremost at police departments – the forces of public order – whose legitimacy is based on an obligation to produce results in terms of public peace and order.  The police are the ones who question individuals and lay the groundwork for the case in the form of a police report.  They provide the raw material that goes to the public prosecutor, whether the offence is use, trafficking or social delinquency.  The increase in arrests of users, mainly marijuana users, may come as a surprise. The police need those arrests to show that they are out there taking care of small-time and big-time trafficking. Trying to do things after an arrest to avoid too harsh a criminal penalty for “ordinary” users transforms judges and other players into tools in an attempt to solve a problem whose roots lie elsewhere.  And of course, the cases referred to public prosecutors and the courts contribute to overall clogging of the system, make for longer proceedings and stand in the way of “personalized” intervention.

Another strong phenomenon that is constantly resurfacing is the professionalization of trafficking in illegal substances.  A recent survey based on a critical analysis of court cases in several jurisdictions (Hauts-de-Seine, Seine-Saint-Denis, Nord) and background interviews with people involved in trafficking brought to light various aspects of the professional nature of trafficking: organized files, increased division of work, mobilization of skills and expertise, traditional techniques of organized crime (intimidation, “hit men”, etc.) and underground activity (having some operations carried out by people who are above suspicion, with or without their knowledge), and money laundering (Duprez, Kokoreff, Weinberger, 2001).  This process of professionalization attested to by the relatively small number of arrests for “trafficking” is manifested in different ways depending on the type of market concerned.  In the case of local trafficking, dealing in marijuana and especially heroin and cocaine has become a separate job, particularly in poor neighbourhoods, that mobilizes resources (relational) and skills (professional).  Entrepreneurship and the desire for social success outstrip – at least for the cases reviewed and the people interviewed – the need to cover the cost of personal use of drugs.  With regard to marijuana-importing rings, there are well-organized structures that provide a better understanding how goods move (logistics, distribution by semi-wholesalers, return of money) and peripheral activities (disguising of cars, driving skills, lodging, laundering networks) that make it possible to generate wealth.  Colombié and Lalam observed similar professionalization related to “synthetic” drugs like ecstasy. They showed how criminal organizations recovered then organized trafficking in these new substances.  This comes as no surprise.  The demand for illegal drugs can only lead to a market structure in which the strongest set the rules, and in that area, mafia-type organizations are the professionals.

 

2. Different uses, integrated users

 

Having painted an overall picture of these changes, we now go back to the different types of drug use taken into account in new public policies.  Socially differentiated use, integrated users, self-managed use: these are the phenomena we are starting to get a handle on today in almost every part of Europe.  One of our objectives in this paper is to describe and understand these processes.

 

From the marginality/heroin/exclusion model to the integrated user model

Taking  into account the wide array of uses and relationships with drugs is a departure from that Decorte calls the “worst-case scenario”, that is, with the marginality/heroin/exclusion model.  That model shaped public policy and professional thinking as well as social sciences research.  We may be fairly familiar today with the role drugs (use and trafficking) play among the population, particularly the most marginalized segments of society (excluded among the excluded, drug addicts with AIDS, characterized by a tenuous connection with social networks and health care structures), but we know very little about segments that are well integrated socially and economically – what are called in France the middle and upper classes and in Anglo-Saxon countries “hidden populations”.[15] Almost a decade ago, Ehrenberg (1991, 1992) suggests a number of ways of linking drug use to social mindsets to encourage people to give up drugs for good.[16]

Around the same time, a series of studies of former drug addicts from different social backgrounds conducted under the direction of Robert Castel identified several options for analysing the social determinants of drug use and societal supports that can help users stop (Castel, 1998, 230), because in spite of accepted ideas and shared beliefs, people do stop.  The research identified two types of drug user: “upper-class users”, who are socially, culturally and economically “endowed” and have “something to lose”; and “lower-class users”, who ultimately have “very little or nothing to lose”, since social failure is part of life. Analysis of the socially different meanings ascribed to practices and trajectories can be related to analysis of the different types of drug addiction, because those outcomes take a variety of forms, even within the various segments of the population.[17]

In France, at least, these options ultimately went largely unexplored.  Why was that?  It may be because of “social demand”, which we define as the common semi-scholarly representations that typically link segments of the population and marginal, peripheral and criminal elements, and proponents of research that is legitimized by “fear of the working classes”.  In fact, social demand is stronger in the lower classes than in the middle and upper classes, in “hot” neighbourhoods than in “trendy” neighbourhoods.  But this type of argument may fall down when it delegitimizes any form of knowledge or investigation of what would primarily be “social problems” rather than sociological issues (according to the old saying from Durkheim: “social is not sociological”).  This shortcoming can also be explained in terms of stigmatization and visibility: on the one hand, the stigma makes some segments (workers), groups (second generations) and areas (the street) visible; on the other, social groups that have the resources can manage their private use (in the comfort of their middle-class homes or behind the heavy drapes of their psychoanalyst’s office).  But the methodological problems that are inevitable in a study of integrated users are not insurmountable, as illustrated by the studies carried out by Decorte, Caiata and Leroux.  Other factors may be come into play, such as those related to traditional research methods.  Since the late 1960s, a whole series of studies have been devoted to marginal segments of the population.  The increasing prominence of the social and economic side of drugs and the decline of the ideological side and the role of drugs in counterculture have in a way extended that tradition.

We know that drugs are not limited to the fringes of society.  Aside from marijuana use, which is a widespread phenomenon that we will come back to later, there are heroin addicts who maintain social ties and use heroin to fulfil social requirements (is this not Caita? ref.). The studies by Cohen (1996) in the Netherlands and Diaz (1996) in Spain showed a wide range of profiles among cocaine users.  Cocaine is not just a luxury drug popular in show business, high fashion and advertising and among stock market traders and financiers.  Studies conducted in North America have shown that cocaine use now cuts across all social classes (Fagan, 1994).  This pattern of use through all social strata is equally valid in France, as cocaine has also become more commonplace among the lower classes.

These practices are not very visible socially and have not been studied a great deal in France.  For example, very revealing studies on students (Moser, Ratiu, 1998; Galland et al., 1995; Felonneau, 1994) did not examine deviance or delinquency (Ballion, 1999). But this is also true in nearby countries like Belgium and Germany (Groenemeyer, 1996).

 

Impact of age and sex           

The introduction of a permanent mechanism for observing drug use referred to earlier sheds greater light on the use of legal and illegal drugs.[18]  These studies update the impact of age, generation and sex on drug use.  The study by Choquet and Ledoux (1999) showed that experimentation with marijuana increases sharply with age and is more common among boys in all age groups.  At age 17, 49.9% of the girls and 50.1% of the boys interviewed said they had tried marijuana; the proportion increased to 60.3% of boys at age 19, for a total of 12,113 individuals.  Twice as many boys as girls use marijuana repeatedly (at least 10 times a year) (23.8%, compared with 12.6%), and the proportion rises to 32.7% among boys 19 years of age (OFDT, 2000). Between the ages of 14 and 18, repeated use of marijuana increases from 2% to 9% among boys; 15% of the 18-year-old boys interviewed used marijuana more than 10 times in the previous 30 days.  The impact of cohort is also significant.  One study of students (n=500) carried out in 1978 and repeated in 1998 showed that lifetime use more than doubled over the period, from 25% to 53%. Among the different profiles, experimentation was steady (13%), occasional use increased from 11% to 29%, and regular use increased from 2% to 11%.

While marijuana use appears to be higher among males, use of psychotropic drugs seems to be higher among females (29% of the girls had used psychotropic drugs, compared with 10.6% of the boys).  However, experimentation with tobacco and alcohol is comparable between girls and boys and increases with age.[19]  Experience with alcohol, meanwhile, varies considerably by age and sex: at 14, 26% of boys and 20% of girls have already been intoxicated from drinking alcohol; at 18, the proportions rise to 71% of boys and 55% of girls.

These epidemiological data have obvious limitations.  As a result, there is little information about the social distribution of substance use.  The study by Baillon (1999) on the behaviour of high-school students not only sought to identify the effect of school type on deviant behaviour, but also put forward some interesting options.  The author divided the sample of more than 10,000 students into three sub-populations: students in a priority education zone (ZEP), students attending schools covered by mechanisms set out in the municipal policy (DSQ, DSU, city contracts) and a group from non-ZEP and non-DSQ high schools.  The ZEP schools had the largest proportions of students from working-class families (more sons of workers and employees, fewer children of executives and middle managers).

The study showed that just over 33% of the students interviewed had used an illegal substance during the year (a marijuana derivative in almost 30% of cases).  However, against all expectations, the use of marijuana derivatives was lower among the ZEP students (23%) than the DSQ students (33%) and the other students (35%), particularly for frequent use (8.7%, compared with 13.2% and 14.8%).[20]  The survey also confirmed the differences between boys and girls: 41% of the boys had used a drug during the year, compared with 27% of the girls.  Still, while the girls from the “other” schools were more concerned about drug use than the girls in the ZEP schools, in vocational ZEP schools, the proportion of girls using drugs was similar to the proportion in “other” schools”.  It also appears that the trickle-down effect is not a major factor in other schools, but is in ZEP schools, where the students in vocational programs are far more concerned about the use of hashish than their counterparts in general academic programs.

Finally, the study showed that there is no contextual effect on drug use.  Baillon noted, however, that ZEP schools could be considered a social environment more conducive to deviance because the proportion of students who had most recently used marijuana was higher than in the other two categories of schools: 19% of ZEP students who reported using drugs, compared with 6 % of DSQ students and 9% of students in other schools (Baillon, 1999, p. 45).

How, then, do we undertake a sociological interpretation of the data we have today?  How do we interpret the social legitimacy that marijuana now seems to enjoy? Is marijuana use an integral part of a lifestyle (for young people)?  Are drugs so popular because they are a device for constructing the individual (Ehrenberg, 1992, p. 55)? How do we interpret the sexual dimorphism reaffirmed by all the studies?  We could say that these practices are part of a “youth culture” or that the differences between girls and boys stem from socialization processes and sexually differentiated normative models (OFDT, 1999). Again, we need studies that analyse the tangible mechanisms.[21]

 

Self-control mechanisms

One thing is certain: it is no longer enough to associate drugs with marginality, exclusion or disaffiliation.  The proportion of “invisible” users is driving the development of new hypotheses.  In other words, self-control techniques must not hide the existence of other methods of controlling drug use: societal control personified by families, neighbours, peer groups, user self-control (Castel, Coppel, 1991).

What is most interesting about Decorte’s study of cocaine and crack users in Antwerp is the choice of criteria: the subjects never sought or underwent treatment.  He showed that it is possible to find a group of “invisible” users, shattering the stereotypes of lacking, illness and criminality.  However, external and formal controls do have an impact on the practices of this group: they discredit individual efforts to achieve self-control or attempts by friends and family to intervene.  The theory is this: the social environment, by developing rules and rituals (that is, informal controls) is what gets illegal drug use under control.  The role of friends, acquaintances, partners, parents and others, counsel and discussion, etc. are elements that help make the social dimension a positive one.  These rules and rituals are part of a learning process that fosters socialization.

Illegal drug use is still considered a taboo by society at large, families and co-workers.  To avoid being socially outcast, the individuals interviewed said they do not disclose their illegal drug habit.  The moment official warnings are perceived as exaggerated or wrong, the gap widens between non-users and users, between formal standards and informal rules.  Hence this contradiction that is all too evident regarding the limits of transmission from generation to generation: every generation of users has trouble passing on to the next the lessons it has learned.  When the process of transferring knowledge is undermined in this way, tragedies tend to recur.

Caiata investigated the strategies used by “integrated” heroin and cocaine users and the resulting lifestyle through a number of qualitative studies in Switzerland.  An integrated user is a user who, in contrast to a known user, balances drug use with other aspects of his or her personal life (work, family, recreation) (Ogien, 1996). How can a person accommodate behaviour that is in direct conflict with the dominant culture?  The sociologist began by identifying four broad categories of strategies for dealing with the risks a person takes: limit the physical consequences of drug use; manage the large expenditures drugs entail; switch between deviance and compliance, being careful to avoid stigmatization; adjust to jeopardy and stress.  These personal strategies are made possible by learning that produces the skills needed to manage drug use.  If, as Caiata points out, the user tends to become a sort of “professional” user, he or she remains at risk of failing.  The paper goes on to develop two case studies of users balancing their personal lives in a world that considers cocaine and heroin use to be unacceptable.  Drug use is a way of assuming social constraints and the roles that being a part of society entails.  Drugs shape the lifestyle.  But the relationship with the substance can also be more peaceful because of all the symbolic work that goes into drug use to normalize the meaning and neutralize the conflict with norms.  This results in two profiles of an integrated user.  Between alienation and approval, there are two sides to modern individuals on whom there is pressure to be themselves.  That is why it cannot be fully understood other than in the macro social context characterized by individual action.

Recent studies on this issue examined substance abuse in sport.  It is a known fact today that participation in high-level sport offers no protection against the use of psychotropic substances, as witnessed by the results of qualitative and quantitative studies.  The studies by Beck, Legleye and Peretti-Watel open the door to comprehensive analysis of the links between sport and drug use.  While there is no obvious link between level of involvement in sport and level of drug use, the authors point out that there is a U curve: for both sexes, use is generally highest at the two extremes of participation in sport (no physical activity and more than 8 hours a week).[22] A typology of psychoactive substance use based on discipline would show the differentiation between those relationships.

Leroux’s article shows that drug use and therefore the associated risks are guided by their own set of rules (passion for the sport, limited involvement in other areas of social life, such as family, school and friends, etc.).  However, it also shows that the path is based on resources that are unevenly distributed.  The article compares the high-level sports careers of athletes from working-classes and affluent classes and highlights the difference in family support and the emphasis placed on competitive sports, the impact of social belonging on the way athletes begin and stop using drugs, and specific methods of managing the stigma of getting “on” and “off”.  During or after participation in sports, the scope of this leeway depends in large part on the social setting.  And if failure to integrate drug use is evaluated on the basis of social dissociation indicators, former athletes from modest backgrounds fare worse than their more affluent counterparts.

 

 

3. Prevention

 

In this context of new discourse and changes in user practices, the institutional system has been doubly tested.  During the 1990s, a whole set of mechanisms emerged amid the successes and failings of the system, marking the development of prevention and support: Boutiques, Bus d’échange de seringues, Sleep-in, Points-Ecoute, etc. Those mechanisms cleared the way for new forms of social intervention promoted through city policies.  They are part of a much broader process of building new reference points.

       Mediation is foremost among these mechanisms.  Development of the concept of mediation not only conveys the public’s desire for productivity and stronger ties between institutions and certain target groups; it also entails the emerge of new occupations that draw their validity from being close at hand (territorial anchoring, ethnic affiliation).  The experiment carried out by the RATP with “big brothers” to deal with “incivilities” was used as a model.  This type of mechanism has since been extended to client service personnel on public transit and in shopping centres, street mediators and other night workers in “sensitive” areas.  There is a new analogy in substance abuse with “front-line mechanisms.

 

Outreach work and “Points Ecoute”

How do the member countries of the European community view “front-line work”?  That is the question examined in a joint study the key elements of which Mougin reports here.  This first field survey inevitably raises the question of whether the new data are comparable, yet the real question is how much the forms of intervention developed in those countries to assist drug users help create a new paradigm.  The question is not self-evident for two reasons.  First, we are dealing with an area in which the objectives and forms of activities can vary dramatically.  The debate over the terminology used in different countries is a good example: do we have to consider that what is called “travail de proximité” in France (outreach work in English) is meant to compensate for the failings of the traditional system, that is, to cover “hidden” or marginalized populations in particular, or is the aim instead to take broader preventive initiatives for a public that is socially better integrated and far more heterogeneous?  While that question was asked in connection with AIDS, it goes back to a time long before its application to drug users.  Mougin showed that since the end of the last century and especially after the Second World War, outreach work has been associated with a series of players (the poor, youth, new youth cultures, “hidden” drug users, users of synthetic drugs) based on political traditions relating to drugs and the priorities of the day, not to mention changes in context and any other changes that may have occurred.[23] This means that in countries that take a pragmatic approach to drugs, like Denmark and the Netherlands, the area has developed more quickly than in countries like France that take a more political and medical approach.

While it appears that outreach work has developed in most countries, the main target being traditional drug users, political recognition of outreach seems stronger in northern European than in the south.  Another discrepancy lies in the institutionalized or experimental framework in which the work is done: in some cases, outreach may be done by health care agencies; in others it is left to various groups (self-help, risk reduction associations, etc.).  The differences in current practices show that there is a limit to this type of comparison and indicate the problems encountered in evaluating something that is always changing.  Perhaps what is needed a challenge that can be taken up to bring about better harmonization

On a very territorial scale, the article by E. Jacob, M. Joubert and S. Touzé analyses the Points Ecoute initiative and the underlying objectives and issues.  Established following the 1997 circular, this mechanism appears to be a product derived from careful consideration that began in the early 1990s and led to specialized care being separated from prevention.  Various factors contributed to its emergence: creating a “preventive stronghold” by taking into account chinks in the social fabric, mental health and the field of substance abuse and high-risk behaviour; developing preventive measures by working on lifestyles and high-risk behaviour among youth and establishing primary and specialized measures; fostering access for populations that stay away from conventional means of intervention; and narrowing the gap between institutions.  In the latter case, the authors clearly show that Points Ecoute are part of an outreach approach in social work and substance abuse treatment.  Ensuring accessibility is a major issue that transcends the diversity of direction that affects the location of Points-Ecoute outlets (in “sensitive” areas or downtown).  The ability to adapt to local contexts must not mask the absence of a model and clearly defined referents in the area of dug abuse prevention.

 

Tapping the experience and abilities of users

A good illustration of the changes in control methods and practices and in the resistance and power issues control raises is the attempt at mobilization or recognition made by drug users themselves.  This phenomenon is not “new”, but the context is completely different from what it was in the 1970s.  It is no longer a simple question of dealing with “former drug addicts” who have expertise and relational and therapeutic skills based on experience, working within a centre, but people who are becoming professionals and challenging institutions in the name of their expertise in a context of change.

Marie Jauffret’s study of self-help groups (Auto-Support des Usagers de Drogues), compared here to other types of intervention (Narcotics Anonymous), clearly illustrates the ambiguity of the actions that are taken.  What these groups have in common is a type of expertise rooted not in a diploma, but in life experience.  Through this process, the emergence of a class of drug users as responsible, independent, individual citizens is analysed.  The decline in the practice of sharing needles (from 48% in 1988 to 13% in 1996) is a good indicator as well as an argument supporting this rise in accountability.  More generally, lifestyle changes, centred less and less on the quest for drugs, occur in a context marked by the development of substitution programs and “front-line” mechanisms.  At the same time, the now-generic category of self-help groups covers very different situations and skills.  The conditions in which the group develops, the role of former users, the range of group actions, participation in the shaping of public policy, methods of funding and opportunities for recruitment vary from group to group.  The ASUD is more focused, more mobilized and more vindictive than NA, but not as radical as Act up; its members contribute to the development of new types of professional approach to AIDS and substance abuse.

The notion of “professionalization” emphasizes skills (not qualifications).  That is what makes ASUD a breeding ground for candidates for the “low-threshold” mechanisms put in place since 1996.  A dual process of socialization is toying with authors who are non-users regarding drug-use practices and players who are former users regarding institutional practices.  But professionalization also has its limits: recruitment problems, professional relocation outside groups that are then deprived of their “best elements”, precariousness, management of dual affiliation, lack of training and outlooks for change, dependence on the institution that hires them, hence the dilemma of professionalized users.

 

It is still too soon – as we saw earlier – to evaluate the impact of the change in the discourse on drugs and the accompanying articles, practical measures and data.  We can probably view the change as a new direction that makes public policy more pragmatic and more closely linked to issues of public health.  There are also signs already that representations and practices do not change at the same pace, which is not surprising; moralizing messages about drugs held sway for years and still do in some works and media; practices have also been accompanied by a client-centred approach and the creation of lasting networks; “strong” institutions like the police enjoy a level of credibility in the fight against drugs and lack of public security that they do not want to lose.  Moreover, the criminal justice system is easier to set in motion than social work and offers a number of solutions, the most of immediate of which is confinement.  The time of institutions is not the time of statements of intent or changes in thinking.  Finally, politicians have their sights set on the next election and refrain from publicly supporting positions that could lose them votes, although some may support them in private.

Disgruntled people might even consider these new directions as a way of using other means to extend individual discipline and control of the public.  In any event, the question merits asking in a general way: how might the new public health issues be considered the expression of an insidious normalizing power?  In a more subtle way, Fassin wonders, urging the poor to take care of themselves so that they can integrate and drug users to use substitution drugs so that they do not contract AIDS, are we not seeing the creation in the most paradoxical way of a policy rooted in physiology that would control individuals and at the same time a policy rooted in biology that would protect the community?  The author goes on to say that this interpretation is not borne out by the facts.  There is a definite gap between discourse, which sets the standards, and practice, which reveals the outcome.  Instead of talking about bio-power, which is often ridiculously ineffective, we should be talking about bio-legitimacy, that is, social recognition of political management of the body.  What is remarkable, in fact, is not the normalization of behaviours and processes, as Foucaldian analysis would have it, but the way social problems are not resolved by, but rather expressed in the most authoritative way through the language of public health (Fassin 1998, pp. 38 et seq.).

This question in a way takes the place of the questions about the extension of social control which were asked in the 1970s (Lascoumes, 1977) and which the first players in the specialized field of drug treatment thought could be resolved with anonymous care (Bergeron, 1999).  Time will tell whether practices related to drugs will confirm the Foucaldian interpretation or whether the language of public health has not only overlain the language of criminal justice, without really replacing it, and just successfully enough to solve the social problem.  We can be certain, however, that the issue of psychotropic substances, legal or illegal, will long be a concern for public authorities.


 

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[1] See European legislation and drug policies (Italy, Switzerland, Netherlands, and some German cities, like Frankfurt), which tend toward the decriminalization of some drug use and the development of public health policy (Césoni, 2000).  Even Sweden, which until now has been a diehard prohibitionist, is beginning to soften its attitude (Boekhout van Solinge 2001). See also the role played by the EMCDDA as an example of coordination.

[2] For needle exchange programs, see Emmanuelli 1997, 1999, 2000 and 2001; Lert 2000; and Emmanuelli, Lert, Valenciano, 1999.

[3] Commissioned by Simone Veil.

[4] Usage et trafic de stupéfiants. Statistiques 1999, OCRTIS, Ministère de l’Intérieur, 2000.

[5] Remember that the ministers responsible for public health and public order have locked horns several times, particularly over the Issue of prosecution of drug users.  Even the 1970 legislation is an awkward compromise between the two ministries (Bernat de Célis, 1992).

[6] Not to mention the ban currently in force in Old Regime societies.

[7] For example, ASUD was supported by the health branch.  See Voir Jauffret 2000, and elsewhere in this document.

[8] Two things emerge from this situation: the studies are predominantly British and American and there is a marked preference in the U.K. and the U.S. for lifestyle studies in a natural setting; and the results of the studies that have proliferated in France since the 1970s (Boullanger, Coppel, Weinberger, 1992) have been "disappointing" shedding only partial light on issues that are crucial (number of users, changes in user habits, tie-In with social or public health Issues, effectiveness of intervention).

[9] Decorte also illustrates the limits of drug epidemiology, which is often based on biased or incomplete data or data that focus on more familiar groups.  There simply are not enough studies to provide us with facts about the lives drug users lead."  See this document

[10] Tendances Récentes Et Nouvelles Drogues.

[11] Quota study of 2,000 people.

[12] Suffice to consider the problems encountered since the 1970 legislation on narcotics was passed and Belgian security contracts (van Campehoudt 2000, Devresse et Cauchie 2000).

[13] OCRTIS data provided by the OFDT.

[14] Belgian prosecutors can delay bringing a case to court indefinitely and can even drop a case if the person charged demonstrates that he or she is no longer using drugs.

[15] This term refers both to well-integrated populations largely unknown (if known at all) to anti-drug and health care agencies and to very marginalized populations that do not use help and support facilities for "drug addicts" and do not take advantage of other resources.

[16] "[translation] Drug use increasingly emerges as a functional nebula stretching between two poles: psychological comfort or well-being, and stimulation of individual performance after the doping model in sport, that is, use of substances that increase the person's psychological and physical ability to deal with heavy social constraints.” (Ehrenberg, 1992, 69)

[17] See in particular Duprez, Kokoreff, (2000, 168-192)

[18] In the 1990s, there were few mechanisms for measuring the social determinants of drug use, but in contrast, social factors in the use of psychotropic medication were studied in greater depth (Le Moigne, 1999).

[19] However, among the small minority who use other drugs (amphetamines, cocaine, heroin, etc.), tobacco and alcohol use is slightly higher than in the other two categories (6%, compared with 3%), especially concerning the most frequent use (3.8%, compared with 0.9% and 2.2%).

[20] The rates for 15 and under and 18-19 were 3% and 16% in ZEP schools, 12% and 13% in DSQ schools and 28% and 29% in other schools.

[21] This sexual differentiation is a recurring problem in criminology, from Lombroso (rev. 1991) to Cario (1992).  The most convincing studies draw on the theory of differential socialization or differential associations and opportunities.  The latter theory explains the growing number of women involved in drug trafficking.  Some studies have identified a more aggressive delinquency related to lifestyle among boys and to runaway behaviour or prostitution more common among girls (Bertrand 1979). A recent wave of theory suggests that the sex gap in deviant behaviour will narrow because of growing similar in opportunities available to boys and girls.  This is true for smoking, in any event, although smoking cannot really be considered deviant behaviour.

[22] However, age has a bearing on the curve: younger people are less active in sport and do not smoke, whereas more intensive athletes are generally older and part of the groups in which the incidence of smoking is highest.

[23] For example, "conventional" drug use giving way to the use of "new" drugs like ecstasy.


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