Cocaine: towards a self-regulation model New developments in Harm Reduction

Introduction

A significant body of research on cocaine users recruited outside captive populations – that is, studies based on samples of users who have not been enrolled through drug addiction services – has been carried out in many European countries and outside Europe. These studies show a variety of patterns and trajectories of use other than “addictive” use.

Similar studies have been conducted on users of different drugs, such as amphetamines and cannabis, with analogous results. The reason for most controlled use lies in a wide set of self-regulation rules users tend to apply to keep drug use at bay and prevent the disruption of everyday life. This perspective is noticeably at odds with the point of view of drug addiction professionals, who tend to focus on addiction as a disease, resulting from the chemical properties of drugs combined with biological, psychological and social deficits of users. It also challenges the social representation of drugs as intrinsically out-of-control substances and of drug users as helpless under the influence of drugs.

By taking cues from users’ self-regulation strategies, it is possible to design innovative operational models for drug services as well as drug policies, strengthening Harm Reduction as an alternative approach to the disease model. This paper illustrates this paradigm shift of moving the main purpose away from elimination and towards regulation of drug use, with the aim of encouraging users’ informal controls while reducing the harm caused by punitive laws and policies.

Key Points

• Findings from qualitative research on regular cocaine users not enrolled in treatment reveal a picture of cocaine use that contrasts with the dominant social image of the use of illegal drugs, focused on “escalation towards addiction”. Instead, cocaine users’ careers are variable, and they tend to vary with life circumstances and environmental conditions. More important, most cocaine users learn control over the drug by setting a wide range of self-imposed rules, aimed at preventing the disruption of their daily life activities.
• Though the prevalent trend in patterns of use is towards more control over cocaine use, many users still go through one or more periods of more intensive use and perceived diminished control. It is not merely that users are unwilling to enter treatment: the drug addiction programmes available at present, dominated as they are by the disease model of addiction, are a poor fit with cocaine users’ experience as well as with the most innovative approaches in health programmes.
• Suggestions drawn from users’ self-regulation abilities can be the foundations for a new operational model. Raising the target for the number of users in contact with drug services does not mean a further medicalization of drug use, but rather the “de-medicalization” of drug services following the “normalization” of the use of illegal drugs. The main feature of the new self-regulation model is the focus on the user’s abilities to be “over the influence” of drugs, as opposed to the traditional image of the powerless addict “under the influence” of drugs. It also focuses on the social context and setting of use, highlighting the relevance of broad social policies and wider issues such as empowerment and human rights in drug policy.
• The self-regulation model is embedded in Harm Reduction, while taking some of its cornerstones in new directions. It can re-launch Harm Reduction as an approach and overarching concept in drug policies, going beyond the well-known set of public health measures to focus on reducing the harm caused by policies, and punitive laws in particular, so as to change the objectives and strategies of drug control.

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