Interview | Sunday, 09 August 2009
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The drugs don’t work

The local drug scene is evolving, with new drugs hitting the market and a whole new generation of ‘atypical’ problem substance users. For psychotherapist ANNA GRECH, a specialist in addiction, this poses a challenge to conventional drug residential rehab

Few issues are as fraught with immediate contradictions as the world of drugs. Hardly a day goes by without the media reporting large hauls of illicit substances such as heroin, ecstasy, cocaine and cannabis by the police. And yet, it seems the availability of all these drugs, and others beside, is constantly on the increase.
And while recent reports suggest that Malta enjoys a very high rate of problem drug users reporting for rehab – one of the highest in Europe, in fact – it seems that more people are seeking therapy for drug addiction today than ever before: many of them relapsers.
With so many apparently contradictions staring us in the face... where does one even begin talking about drugs in Malta?
“From what I can see, the local and European drug situation has not improved,” Anna Grech says when I ask her to give an overview of the changing environment of substance abuse.
Anna is a professional psychotherapist who has specialised in drug and alcohol addiction issues, and has therefore seen a good deal in her career. She has worked with government, compiling reports on Malta’s drug situation for the EU, and also with agencies involved in rehab. Now she has set up a private practice together with fellow psychotherapist Mariella Dimech, and deals with persons with a range of problems, including drug and alcohol abuse.
“For one thing, cocaine is more widely available than ever and also cheaper nowadays. Ecstasy – or at least, substances sold as ‘ecstasy’, even if they often do not contain MDMA – is much cheaper, too. The average age of reported users is also getting younger. And there are new synthetic drugs on the market – some of which are not controlled substances, and are therefore not illegal...”
Today’s “typical” drug users are referred to as ‘ACCE’ – Alcohol, Cocaine, Cannabis and Ecstasy – and people tend to use a concoction of these substances.
“People requesting therapy therefore tend to be ‘poly-drug users’. They do have a preferred substance of choice; however throughout their drug using career they tend to mix a wide variety of drugs: even pills, prescribed or not.”
This marks a significant departure from the landscape of yesteryear, whereby persons seeking drug rehabilitation therapy tended to suffer predominantly from heroin addiction.
And this is not the only change Malta’s drug scene has witnessed in recent years, either. “The type of person seeking treatment today is not exactly the same as it used to be in the past,” Anna says, alluding to the widespread (if inaccurate) perception of the “typical” drug addict as young, unemployed and overwhelmingly male... mostly from underprivileged socio-economic groups, or coming from severely dysfunctional family backgrounds.
Naturally, these cases still exist, and continue to make newspaper headlines on a regular basis. But from Anna’s experience this sort of generalisation overlooks an entire spectrum of “new” problem drug users, who are often not reached by the system.
“We are now seeing more female users than before,” she points out. “And it’s no longer the case that problem drug users come mostly from low socio-economic brackets. I would say there is a mix out there: drugs touch people from all sorts of social and family backgrounds, from the very poor to the very well off. Drug addiction crosses all social classes...”
Anna’s research into substance dependency has meanwhile led her to categorise drug use into three basic types: 1) social or recreational use; 2) abuse; and 3) addiction. However, the distinction might not be visible to everyone at a glance. What’s the difference between ‘use’ and ‘abuse’?
“A person can use a drug once, and never touch it again, or at least very rarely or occasionally. This happens when drugs are used out of curiosity, as a phase during adolescence or maybe socially such as the one-off occasion at a New Year’s Eve party. You can’t really call that ‘abuse’: more misuse, if anything. In fact, when lifestyle surveys are conducted for research purposes, the ‘drug-use’ questions are always divided into three: people are asked if they’ve ever used drugs in their lives; if they’ve used drugs in the last year, or in the past month...”
Anna also cites alcohol as a good example of a substance which can be consumed without being abused: “A person can have a single drink, or drink socially without ‘abusing’ alcohol. The occasional but limited use of alcohol, for instant, is distinct from regular abuse over a long period of time: loss of control over one’s use and the compulsion to use, which characterizes addiction...”
But it is abuse and its progress to addiction that interests Anna above all other stages, as it is largely when addiction kicks in that the drug user will find he or she has a serious problem.
“Addiction always begins with social use and abuse, but is far more than just a case of ‘using a lot of drugs’,” Anna says when asked to define the term.
The main features, she explains, include a compulsion to use a drug or the inability to abstain from that drug, despite being fully aware of the negative consequences; an inability to control one’s drug use; an increase in tolerance to the drug (i.e., more of the drug is needed to feel an effect), and feelings of craving and withdrawal when the drug is not used.
“You realise that addiction is kicking in when the amount of time spent thinking about the drug, and how you’re going to obtain it, increases until it slowly becomes the centre of your life. Everything else – work, friends, the family and other social activities – all fall by the wayside.”
Anna maintains that there are people who use drugs and alcohol without becoming addicted; in fact the majority of persons who experiment with drugs in their lives will not go on to become “junkies”.
“However, unfortunately some people do become addicted, and the consequences are often dramatic and at times fatal.”
So what type of person is likely to get addicted in the first place? The answer is not as clear-cut as many might imagine.
“In theory, anyone can become an addict, because it is not possible to know beforehand who is going to and who isn’t. It is generally only with hindsight, once the problem emerges, that the risk factors become more apparent...”
Specific risk factors include a family history of drug or alcohol use; a personal history of violence and abuse; socio-economic background; low self-esteem; and early exposure to drugs and/or alcohol. There are also persons who suffer from any of a number of underlying mental disorders – depression, anxiety and antisocial personality disorder, to name a few – and these sometimes turn to drugs or alcohol to ‘self-medicate’.
One highly important consideration is age: Anna maintains that the risk is invariably greater for those who start their drug habit young.
“Studies have shown that the younger a person is when first exposed to drugs or alcohol, the more significantly vulnerable he or she will be to developing related problems in adulthood.”
Apart from obvious issues such as inexperience, naivety, exuberance and experimentation, there are also neuropsychological reasons to account for the increased vulnerability of the young.
“Because adolescents’ brains are still developing in crucial areas like decision-making, judgment, impulse and self-control, they are especially prone to risk-taking behaviour. This also makes them particularly vulnerable to the neurological changes that occur as a result of drug use...”
So what happens when someone with a drug problem shows up for therapy?
“The first important thing is to assess the severity of the case,” she replies. “It depends on the individual, but generally one looks at the medical side of things and aims at stabilizing the person. If we are dealing with a heroin or cocaine addiction issue, the patient must first detox before any kind of psychotherapy can be tried. There is no point in psychotherapeutic interventions with a person whose drug use is still chaotic. It is not enough to treat the symptoms of drug abuse; one must also get to the underlying causes, which sometimes involve areas outside the psychotherapist’s immediate control.”
Anna points out how, for some people, home is not a drug-free environment. “In fact, in many cases home is the origin of the problem, and the patient will have to be accommodated elsewhere if they are going to recover...”
Another issue that requires immediate attention is the person’s mental stability. Drug addiction is very much linked to psychiatric conditions like depression, anxiety, personality disorders, etc, and these often entail the intervention of a psychiatrist.
“Persons with drug problems have a range of emotional, familial, social, financial, employment and legal problems, which very often precipitate relapse or become ‘high-risk situations’. Equipping the person with awareness, a good support system and the appropriate knowledge and skills to face these issues is paramount to sustained recovery.”
Like other active agencies such as Sedqa, Caritas and Oasi, Anna Grech also views alcohol through much the same lens as any other substance that can give rise to addiction.
“Persons coming for treatment with alcohol problems do tend to be older, however. Whereas the average age of drug addicts seeking therapy tends to be mid-20s, for alcoholics it’s nearer 40 to 45. This could mean a number of things, but generally it takes longer for alcoholics to realise they have a problem than for drug addicts...”
Part of this perception may be accounted for by the simple fact that, unlike illegal drugs, alcohol is socially accepted, and up to a certain extent you could even say its consumption is encouraged. From the addiction therapy perspective, alcohol therefore poses a particular danger, as it is often perceived as a “legitimate” alternative to drugs. Anna gives the example of a person recovering from drug addiction, who has been clean for some time, but then goes to (for instance) a wedding or a party, and finds it difficult to resist the temptation to drink.
“The attitude would be: ‘I’m only having a drink. I’m not doing drugs’. But this overlooks the fact that alcohol, although legal, is nonetheless a mind-altering substance, and it affects the exact same brain pathways seen with all illegal drugs, including heroin, ecstasy and cocaine.”
For this reason, a simple whisky at a wedding, for someone with addiction problems, can trigger off a craving for drugs and undo the positive effects of therapy. Anna’s recommendation? Abstinence.
“For those recovering from drug addiction problems, my advice would be simply to stay away from everything... even the occasional drink. I know it’s difficult, but it increases one’s chance of recovery.”
But Anna herself acknowledges that this basic principle doesn’t apply to all cases equally. “Classic alcoholism is not the only alcohol-related addiction problem we encounter. A more widespread but less recognised problem is binge drinking.”
Binge drinking is defined as drinking alcohol with the specific intention of getting drunk. Unlike an alcoholic (or for that matter, a problem heroin user), a binge drinker does not require alcohol to maintain day-to-day functionality.
“A binge drinker will not drink every day – in fact in some cases they would not touch alcohol for months. But then, they will drink heavily for a short period.”
This phenomenon is far more widespread than alcoholism; and while not as immediately life-threatening, binge drinking poses its own unique challenges. “The abstinence model clearly doesn’t work with binge-drinkers, as these people would be abstinent for long periods anyway. In a nutshell, treatment has to be tailored to the individual.”
Nor are these problems limited to alcohol-related cases. The same general principle also applies to new trends in drug abuse: apart from junkies, there are also users who turn to drugs sporadically: for instance, only on the weekend, or only on particular weekends, or at events such as concerts, etc.
“A lot of people fall outside the traditionally recognised ‘classic’ addiction scenarios, and these are the ones who slip through the net. If you look at problem heroin users – I’m talking about people who have to inject every day, or go into withdrawal – these people tend to be reached by the system. Others, however, who use drugs maladaptively, but aren’t the classic addict, often don’t realise or admit they have a problem, and are therefore more resistant to treatment. ”
On the other hand, it is estimated that over two-thirds of all Malta’s problem heroin users are somehow reached by the system. This is good news when viewed in the context of international statistics (in the US, the equivalent rate is 0.02%); but this must be counterbalanced by an abnormally high relapse rate, which Anna estimates at anywhere up to 90%.
“Very, very few people make it the first time round. I would say that the most vulnerable period is in the first year: from a psychological perspective, the person is emotionally and psychologically vulnerable; and from a social perspective, there is a need to reintegrate back into society, and this often entails changing friends, not frequenting the same places, etc. In young addicts, the social aspect of recovery is often very difficult...”
Recovering addicts, Anna explains, often experience cravings, and in that moment their ability to recognize the consequences of drug use becomes impaired.
“That is why complete abstinence from alcohol and drugs, avoiding places and persons associated with past drug use, a strong social support system that helps the person integrate into society, effective coping skills, sustained after-care and most importantly the decision to stop, and the belief that one is going to succeed no matter what... these are all contributing factors that decrease the chances of relapse.”

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