The W.o.D, Spaces of Change
Neurochemistry
The W.o.D Substance use treatment system
Criminal legal controls such as those from the courts, or formal social controls such as those from the other institutions, coerce clients to either comply with treatment or face other harsh consequences, like incarceration, the termination of parental rights, or losing public benefits.
Treatment providers monitor client compliance and abstinence by conducting and observing routine urine drug tests, and providers are often in regular contact with referral sources about client progress in treatment.
Any drug use or negative progress reports can be used as grounds to sanction those on probation, parole, or in drug court which can lead to incarceration and, in cases of drug courts, longer sentences than if participants had accepted a jail sentence.
Clients referred by other sources can also face ramifications for positive drug tests or treatment non-compliance, impacting child custody hearings as well as their ability to secure certain social services and resources, stay enrolled in school, or remain employed.
Problems
A strong champion of the idea that 'inequality is not inevitable', Nobel Prize-winning economist Joseph Stiglitz reminds us: '[I]inequality is cause and consequence of the failure of the political system, and it contributes to the instability of our economic system, which in turn contributes to increased inequality – a vicious downward spiral into which we have descended, and from which we can emerge only through concerted policies' (2012: xxxix–xl).
What does this rapid review of recent evidence on inequality tell us further about this relationship of inequality and politics, and how we might break this 'downward spiral'?
First, the power cube lens points to the dynamic and multifaceted aspects of the relationship between inequality, power and political action, and therefore how its dynamics may take differing forms at different moments and settings.
This broader lens helps us to realise that we cannot understand the links between inequality and political behaviour by only looking at public participation through traditional mechanisms of voting and representation.
This latter finding may help to explain the two competing understandings of the links between inequality and participation, through traditional mechanisms of voting and representation.
This latter finding may help to explain the two competing understandings of the links between inequality and participation, which we discussed at the beginning of this article.
If one understands participation in narrow terms, then our lens may focus on engagement in the political institutions and processes which are most affected by inequality, and therefore from which those concerned about inequality may be most disengaged.
Alternatively, if we look more broadly at movements to expose hidden and invisible power, and participation in peoples' own claimed spaces rather than those to which they have been invited, then we may have a different view, and realise that there are many forms of resistance to inequality which are in fact emerging outside of traditional channels of participation.
For activists and policymakers concerned about how we construct and widen these pathways to a more equal world, the power cube lens challenges us to think about the multiple entry points for doing so, and the need to simultaneously address the forms, spaces and levels of power that produce and protect inequality.
For instance, using the power lens helps us to see that the relationship of economic inequality to political inequality is not just about policy change alone or about shaping who participates in formal political processes, as important as these may be.
Rather, the relationship also shapes – and is shaped by – more hidden forms of power, which define the rules of the game, and in turn affects aspirations to engage in the first place.
vReferral sources influence the type of care that clients receive in facilities, including evidence-based treatments. Research suggests that only 5% of clients with opioid use disorder (OUD), who were referred to treatment from the criminal legal system, received either methadone or buprenorphine, compared to nearly 40% those who were not referred by the system.
This represents an extension of a broader problem within the criminal legal system wherein access to these gold standard medications for OUD is almost non-existent in most jails and prisons across the U.S.
Drug war logic is also deeply rooted in the restrictions for prescribing and dispensing methadone and buprenorphine since they are controlled substances under the oversight of the Drug Enforcement Agency, a federal law enforcement entity.
When taken in effective doses, these life-saving medications can cut the risk of overdose and all-cause mortality dramatically among people with OUD.
However, due to tight federal restrictions and guidelines for these controlled medications, patients can be subjected to routine drug testing, counselling requirements, daily clinic visits, and observed or highly monitored medication dispensing.
Patients deemed non adherent to medications or who test positive for other drugs can then be subjected to dose reductions, required to attend treatment more frequently, or even terminated from care altogether.
The tight restrictions on both methadone and buprenorphine, combined with the oversight of the DEA, create obstacles for prescribers and stigmatise these medications by conveying that they cannot be used like other medications in routine healthcare.
These policies have also contributed to striking racial disparities in who receives buprenorphine versus methadone due to costly co-pays and insurance coverage issues. Studies also suggest that the DEA’s involvement in monitoring buprenorphine has made pharmacies reluctant to stock the medication or to dispense it to patients for fear of triggering an investigation. Ultimately, it is estimated that only 10% of all people with OUD receive these medications
Providers can take steps to extract the drug war from our substance use treatment system, through their conscious and judicious documentation of treatment progress since those records could be used by criminal legal and other referral sources in decisions about clients and their families.
In addition, eligible buprenorphine prescribers should begin prescribing to patients and join advocacy efforts to change policies to expand access to buprenorphine and methadone through looser restrictions.
