Addiction Research and TheoryJune, 2005, 13(3): 231–243

Applying cognitive policy analysis to the drug issue: Harmreduction and the reversal of the deviantization of drug usersin Britain 1985–1997

HERVE HUDEBINE

Centre de Recherche sur les enjeux Contemporains en sante publique UFR Sante,Medecine et Biologie Humaine 74, rue Marcel Cachin 93017, Bobigny Cedex, France

(Received 15 January 2004; accepted 19 November 2004)

AbstractThe aim of this article is to assess the extent to which the advent of harm reduction policies brought areversal of the ‘deviantization’ of heroin users. In order to do so, the analysis will be based on the conceptof policy ‘‘paradigms’’ or belief systems. Such a theoretical and methodological choice involves twoadditional (underlying) objectives. The first is to show how the application of public policy theorycan harness a better understanding of the drug issue. The second is to demonstrate that case studiesconducted in the drug field may also in turn contribute to useful questioning of both the theoreticalbasis and design of some policy analysis models. First, the application of the above mentioned approachto drug policy is discussed. The evolution of the different components of British drug policy is thenanalysed. Finally, amendments to public policy analysis models based on the concepts of paradigmsor belief systems are suggested, that may help interpret the evolution of British drug policy afterthe advent of AIDS and its impact on the social representation of drug users.

Keywords: Deviantization, drug issue, policy paradigms

Policy analysis based on the concepts of policy paradigms or belief systems

Overview of the analytical framework

Proponents of the approach based on the concept of policy paradigms or belief systemsconceive public policies as responses to the social construction of problems (MacGregor,1999). As such they are social and political representations of a problem which can bebroken down into several components, namely the normative, cognitive and instrumentaldimensions of policy paradigms (Muller & Surel, 1998). Public policies are underpinnedby ‘‘metaphysical’’ and value choices, which are compatible with or reflect fundamental

Correspondence: Herve Hudebine, Centre de Recherche sur les enjeux Contemporains en sante publiqueUFR Sante, Medecine at Biologie Humaine 74, rue Marcel Cachin, Bobigny Cedex, 93017, France. E-mail:hhudebine@free.fr

ISSN 1606-6359 print: ISSN 1476-7392 online � 2005 Taylor & Francis Group LtdDOI: 10.1080/16066350500053521

social norms. Drugs policies are based on a set of such fundamental assumptions: drugabuse undermines self control, human dignity and social cohesion. The fight againstdrugs may therefore justify infringements on individual liberties.The policy process can then be analysed as a succession of more and more specific

reinterpretations of the originally quite abstract normative matrix of the representation ofthe problem (Warin, 1995). Satisfying the metaphysical and normative priorities underpin-ning the social representation of a problem and its solutions first requires the elaboration ofstrategic frameworks of action: policing, treatment and prevention strategies in the case ofdrugs. These form the ‘cognitive’ dimensions of the policy paradigm as they refer to theknowledge and theories of the causes of the problem and its solutions. They lead, inturn, to the production of more detailed guidelines, technical specifications, codes ofgood conduct or guidelines of good practice. Policy analysts then identify the instrumentalcomponents of the policy paradigms, namely more minor decisions related to detailedresource allocation, administrative rules and statutory interpretations.

Relevance of the analytical framework to drug policy and issues raisedby the deviant status of heroin users

Several elements are at stake in the above mentioned process, for instance, the social status,interests and identity of the groups and professions involved are also at stake. This is true forpolicemen, the medical profession and drug workers but also for the heroin users them-selves. A policy paradigm may therefore equally be considered as an image, a set of rulesand representation defining and governing the relations of specific groups or sectorswithin the society.One specificity of drug policy in this respect is that it defines heroin and other illegal

substance users in potentially contradictory ways: delinquant and deviant, but also sickand/or socially marginalized persons. This reflects the duality of drug policy. Like anyother policy it can be analysed as performing essential political functions of socialregulation and legitimization of public authority (Jobert & Muller, 1987). However, inthe case of drugs, it could be asserted that this is achieved in two simultaneous butcontradictory ways (South, 1999). Drug policy may indeed be interpreted as an attemptat fostering the social inclusion of marginalized sections of the population (Castel &Coppel, 1991). However, the marginalization of this population can be analysed asresulting from a process of deviantization that is also initiated by the government(Schur, 1980).This is highly significant because, before the advent of AIDS, the response to the 1980s

heroin epidemic brought about an exacerbation of the above mentioned contradiction.There was no coordination between the reinforcement of repressive and preventive policiesaimed at eradicating the ‘worst social threat since the world war’ on the one hand, andthe development of a more pragmatic, multidisciplinary and community based responseon the other. It could be said that political discourse, repressive and primary preventionpolicies stereotyping heroin users had ‘deviantizing’ effects (criminalization and socialmarginalization with ensuing health consequences) that community care policies increas-ingly purported to be correct. The adverse effects of repressive and preventive policiescould be unintentionally aggravated by the rigid treatment policies practised in the clinicalsector, which led to the exclusion or self exclusion of heroin users not yet sufficientlymotivated to attempt abstinence.By risking to extend the health costs of the contradictions of drug policy to the rest

of society, and thereby making them visible, AIDS would ‘‘force a process of change’’

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(Stimson & Strang, 1990). Preventing the epidemic required a degree of pragmatic accep-tance of drug use to make it safer, and improving both the social inclusion and access to careof addicts. Such harm reduction measures could therefore have facilitated a reversal of thedeviantization of drug users observed in the preceding years.

Applicability of the model to drug policy

As it offers a framework for the analysis and interpretation of policy change and a socio-political interpretation of its outcomes, using an analytical framework based on the conceptof policy paradigm to assess this hypothesis is attractive. However, it is first necessary toconsider this analytical model more closely and to discuss its application to the studyof drug policy. With regard to policy change, this approach is founded on a set of assump-tions concerning the type of factors likely to disturb established policy paradigms and theensuing evolution of those. This approach has been developed to encompass the localand micro-social levels of policy making and implementation, which however, raisesquestions regarding basic assumptions of the initial model that become even more acutewhen the drug issue is considered.

Factors likely to bring about change in a public policy paradigm. Some of the factors likely tobring about change in a public policy paradigm are of direct relevance to the drug field.Change may, for instance, result from the social reproduction of one policy sector, orone social group, becoming disjointed from the modalities of the social reproduction ofsociety as a whole. Regarding drug use, some authors have noted that it becomes a politicaland social issue affecting certain sections of the population when the consumption of sub-stances escapes customary ‘‘endogenous social controls’’. This is often the case in periods ofsocial crises and mutation and is more apparent when underprivileged sections of thepopulation are affected (Pinell & Zafiropoulos, 1982). ‘‘Exogenous’’ (Castel & Coppel,1991) modes of social control are then frequently introduced or reinforced. Worries of asimilar nature sparked the reinforcement of drug controls at the end of the 1960s. In thefirst half of the 1980s, the ‘democratization’ and spread of heroin use provoked further,albeit, as noted above, contradictory, reforms of drug policies.Other factors of change include evolutions in scientific knowledge or the advent of dis-

turbing events. Examples in the drug field include the discovery of the virtues of methadonein the treatment of dependence (Preston, 1996) and the advent of AIDS. Such events, and/or the emergence of new policy actors (the rise of the voluntary sector in the drug field forinstance) may initiate debates about the relevance of prevailing policy paradigms in changedcircumstances. In the above mentioned example the rise of the AIDS threat was followedby discussions regarding the relevance of uniform short-term prescription treatments,the exclusive priority given to abstinence or, even, the adverse effects of prohibition andrepressive policies.

A model of change. In cases of disturbance of an established policy paradigm, policy ana-lysts using the paradigm approach assert that the leaders of the sector affected will react in amanner similar to that of the scientists leading a school or a discipline (Majone, 1991). Theleaders of the dominant ‘‘advocacy coalition’’ within a policy community will first resistchange, then concede modifications of the policy paradigm they support at an instrumentallevel, and rarely (if the new arguments are convincing or their advocates are resourceful

Applying cognitive policy analysis to the drug issue 233

enough) at a cognitive level. The ‘fundamentals’ (or normative core) of a policy paradigmwill be rarely challenged and even more rarely modified. Once change has been successfullyresisted or various degrees of modification of the paradigm have been conceded, itis asserted that the life of the policy community will go back to a level of normality andstability (Surel, 1995). This implies a restoration of the coherence between, and wideagreement on, the normative, cognitive and instrumental dimensions of the policy paradigm(Muller, 1990).Analysts also identify policy brokers (Jenkins-Smith & Sabatier, 1993) or mediators

(Jobert &Muller, 1987) who play an essential role during this process. They attempt to con-ciliate differing views regarding necessary and acceptable change, for instance, the beliefs ofthe groups and professions involved in one or several sectors on the one hand and the widerpolitical orientation of the government on the other. Key players of this type are found inthe drug field. Senior civil servants may have their own views but also attempt to brokercompromises between the governmental and policy community views. Professional andvoluntary sector leaders, for instance, at SCODA (Standing Conference on Drug Abuse,now Drugscope) act as representatives of the policy community, attempting to presenta united front.

Issues raised by the analysis of changes affecting drug policy. However, even though severalaspects of the cognitive framework make it a seductive proposition, some issues have tobe kept in mind when analysing drug policy change. Not all the hypotheses inferred fromthe cognitive framework may be relevant. A case in point would be the assumption thatthe drug policy paradigm was/is coherent and the object of a wide agreement in ‘normalperiods of stability’. This may hold true as far as the political level (where normativedimensions are reasserted and objectives discussed) is concerned. However, one couldwonder about the contradictions between the public health and public safety sidesof drug policy. An example of permanent, if often muted, lack of agreement is found inthe frequent critiques voiced by voluntary organization actors and health professionalsregarding the adverse effects of repressive policies. Finally, continuous debates anddisagreements also seem to be the norm as far as the treatment and care side of drugpolicy is considered.These issues become even more acute when further developments in the approach based

on policy paradigms are considered. Early proponents of the analytical model had focusedon central or national policy making. Other scholars suggested that if the policy processcould be characterized as a succession of more and more specific processes of negotia-tions/reinterpretations of norms, the local and micro-social levels could also be considered(Warin, 1992, 1995). Their analysis took into account the discretion of the subordinatesand street level bureaucrats in the interpretation of the bureaucratic norms, with pos-sibilities of evasion but also of feedback and incremental modification of the policies in abottom-up manner. Interestingly, the ultimate negotiation/reinterpretation of the normstaking place with the interaction between street-level workers and services users was alsoconsidered. It appeared that frontline workers tended to use their discretion in order tominimize the disruptions in their working environment, which could involve bending therules in order to satisfy the users, while still preserving a relative compliance with thebureaucratic norms. A ‘‘chain of successive negotiations/reinterpretations’’ (more andmore specific) of the components of the policy paradigm with the ‘‘state’’ at the one endand the public service users at the other, was identified. Ultimately the identity of theservice users was recognized and their ‘‘social inclusion’’ ensured. As successful harm

234 H. Hudebine

reduction strategies require a recognition of the health and social needs of drug users,as well as a pragmatic negotiation about the behavioural changes to be achieved, thishypothesis is attractive.However, the fact that more levels of representation and governance are considered may

mean that the occurrence of discrepancies between them becomes more likely, especiallywhen drug policy is considered. Politicians may equate public safety and public healthpriorities, but frontline workers (be they on the health or public safety side) have to makeactual choices thereby placing themselves in contradiction with one type of priority.Preceding comments have demonstrated that the cognitive approach is both relevant to

and challenged by the study of drug policy. Using this framework to analyse the historyand impact of harm reduction measures would therefore offer the opportunity to assessthe deviantization reversal hypothesis and to test or amend the theory. As the validity ofdistinctions established between different components of the cognitive frameworks fittedempirical observations, it was kept. In view of a multi-level analysis, it was assumed –and then observed – that, although the actors involved may have their own idea of whatdrug policy as a whole should be, their work usually regards one type of component ofthe cognitive framework. Politicians would deal with normative choices, members of thepolicy community with the cognitive aspects while instrumental and/or more detailedchoices would be issues for local decision makers and, to some extent, frontline workers.However, hypotheses regarding relationships between the different levels of governanceand representations in periods of ‘stability’ and ‘change’ on the one hand, regarding theoutcomes of changes for the groups affected on the other, would be left open.

Evolution of the political discourse about drugs

The period preceding the emergence of the HIV threat was characterized by a rise in therhetoric of the war on drugs, inspired by the fear that in the UK, as in the US, theheroin epidemic would undermine the fabric of society (MacGregor, 1989). However,the knowledge of the possibility of HIV infection through injecting provoked a rapidchange in the governmental stance. Even though drug users were still presented in anexcessively grim manner, the 1986 campaign acknowledged that abstinence is sometimesa utopian goal (Rhodes, 1990). Pragmatic advice about clean injecting therefore becamepart of the governmental campaigns. The strategy of harm minimization was officiallyendorsed by the Secretary of State for Health in March 1988 and figured among theobjectives of the governmental programme published by the Home Office. Several authorshowever, suspect that this rhetorical turn was half-hearted or forced by the circumstances.While the prevention of HIV among drug users was recognized as a priority superseding theabstinence goal, the majority of known drug users were still processed through thejudicial and penal systems (Pearson, 1991) and the enforcement strategy tightened(Berridge, 1991). The launch of the Drug Prevention Initiative in 1989 with, amongother objectives, the reassertion of the primacy of primary prevention can be analysed asa reaction against the risks of the normalization of drug use implied by the officialacceptance of the harm minimization strategy (Dorn & South, 1994, p. 300). This wasalso confirmed by an interview with a former MP and leader of the All PartyParliamentary Group on Drugs. Further, similar reactions can be identified such as MrsThatchers’ strong declaration against any possibility of normalization of drug use in 1990(Henman, 1995). These examples lend credence to the assertions that the official politicalendorsement of harm minimization strategies at the height of the concern about the HIVwas a brief phase in a war-like situation (Berridge, 1998). Other examples support this

Applying cognitive policy analysis to the drug issue 235

type of interpretation. While the objective of a reduction in the number of injecting drugusers infected by the HIV virus had been reasserted in The Health of the Nation in 1992,it apparently ceased to be considered as an exceptional priority in 1993. As the rates ofHIV infection among drug users were much lower than expected, a testimony to the successof the prevention policies pursued according to Stimson (1996), the dedicated ring-fencedmonies were terminated (Fleming, 1995). One year later, a Conservative minister launcheda task force to review services for drug misusers. Brian Mawhinney was very critical of thegoals, efficiency and management of street agencies. He hoped that the task forcewould conclude in favour of abstinence-geared treatment at the expense of overly liberaland irresponsible harm reduction practices.1 Regarding the anti-liberal turn of drugpolicy under Mawhinney, see Berridge (1996).Meanwhile the contradiction with the enforcement side of governmental strategy was

increasingly apparent. For instance, in 1994 the Home Secretary insisted on the necessityfor more punitive ‘get tough’ measures and issued a reproof to the police for adoptingmore liberal cautioning policies (South, 1998). Although a ‘softening’ of the enforcementstrategies could never have been advocated publicly and explicitly at a political level, it ispossible to assert that such declarations went against the grain of previous orientationssuch as the recognition of the prevention of AIDS as a chief priority in 1988 or thelaunch of arrest referral schemes (Pearson, 1994).Even when the drug-related harm reduction objective was reasserted, it was blurred and

declined in the hierarchy of governmental priorities. In 1995, the notion of harm reductionwas omitted from the initial draft of the new governmental programme, Tackling DrugsTogether (HMSO, 1994) but was included in the final version (HMSO, 1995), althoughat the bottom of the hierarchy of priorities and with the emphasis put on the reduction ofcommunity safety risks. Little change in the priority given to the symbolic managementof drugs policies and in the ambivalence of their stated goals could be observed after1997 and until 2001. References to the reduction of the health risks associated to druguse almost disappeared from governmental programmes. This could be interpreted as asign of the fact that priority was again given to the symbolic dimensions of drug policies(respect of the international agreements, anticipation of the reactions of the public anddependence treatment as part of fight against crime).

Evolution of the cognitive dimension of the drug policy paradigm

The shift away from harm reduction at the political level was not mirrored at the cognitivelevel, where senior civil servants, representatives of professions and voluntary organizationsdiscuss policy strategies. There, the endorsement of the harm reduction strategy predatespolitical decisions and survives the above mentioned political reversal, but the consensuswas not immediately and easily reached. Senior civil servants, doctors/advisers and theChief Medical officer in the DoH lobbied in favour of harm reduction and mobilized toobtain additional funding from the government (Donoghoe, Stimson & Dolan, 1992).The senior and medical civil servants within the drug policy unit decided not to stoplocal syringe exchange initiatives while, until September 1986, ministers opposed theprinciple. However, reluctance to accept the harm reduction strategy was not observedamong politicians only.

1Interview with a member of the Task Force to Review Services for Drug Misusers.

236 H. Hudebine

Such a move involved a new extension of the voluntary sector and could interfere with theabstinence-aimed approach prevailing within the clinical sector. Although not all thepsychiatrists were opposed to it, this means that the agreement reached by the AdvisoryCouncil on the Misuse of Drugs (ACMD) in 1988 was not necessarily whole-hearted ordevoid of ambiguity. A potentially contentious point was the motivation for and the long-term consequences of the priority given to harm reduction at the expense of abstinence.It was, for many members of the ACMD, especially representatives of the clinical sector,a reluctant concession made on humanitarian grounds. However, such a move could beinterpreted by others, more liberally minded actors in the field, as a first step towards agradual acceptance of the normalization of drug use. Indeed, although the abstinencegoal still figured in the 1988 ACMD report, large sections of the voluntary sector andsome General Practitioners (GPs) would tend to overlook it (Stimson, 1995, p. 703).That a shift back towards a more orthodox view (Fleming, 1995) later occurred within

some sections of the policy community is therefore not surprising, as members of the clin-ical sector were concerned that overly liberal interpretations of harm reduction were prevail-ing on the ground. This gave rise to a controversy which the DoH attempted to allay byconvoking a group of psychiatrists and GPs with the responsibility to provide a preciseinterpretation of the 1988 ACMD recommendations. The 1991 guidelines of good medicalpractice (Department of Health et al., 1991) reaffirmed the role of the clinical specialistsand reasserted abstinence as a primary goal. As such, they could therefore be interpretedas an attempt to clarify the potential ambiguities of the initial consensus on harm reductionstrategies at the expense of more liberal interpretations. The trend was somehow confirmedby the 1993 ACMD AIDS update report. While acknowledging the positive results of harmreduction campaigns, it also stressed that primary prevention had been neglected and thatabstinence constitutes the best way to prevent the spread of the infection (Advisory Councilon the Misuse of Drugs, 1993). The conclusions of the 1996 Independent review ofDrug Treatment Services in England, with prominent psychiatrists in its staff, were similar.The psychiatrists successfully fended off political attacks regarding harm reduction byreasserting its evidence base and laying out strict management guidelines and treatmentprocedures. However, it could also be said that this shielding operation had its rewards.The Task Force report (Department of Health, 1996) can be read as a reassertion ofboth the role and views of the treatment specialists. Similar comments could apply to the1998 guidelines strictly limiting long-term maintenance treatment to be prescribed onlyunder the supervision of specialists.Preceding comments show that, although there was somehow a redefinition of harm

reduction in a more orthodox manner, as opposed to the shifts observed in the politicaldiscourse, the principle was not obliterated within the policy community. One couldtherefore conclude that a consensus between the political class and the members of thepolicy community on harm reduction can only be observed in 1988. Even then, the dualityof the drug policies did not disappear at a political level while the adverse social and healtheffects of the enforcement were still pervasive (South, 1998, pp. 92–93). This divergencecan be attributed to the differing priorities of politicians and members of the policycommunity (Berridge, 1991, pp. 186–187; MacGregor, 1998, pp. 133–134; Stimson,1990, p. 121). The former have to be seen to respond to their international engagementsand to the perceived demands of public opinion. Hence the priority given to symbolicmeasures and declarations. The latter, especially on the social and sanitary side ofthe drug policy, are more concerned with the actual achievement of public healthor social results although they do not always agree on their definition and the meansto achieve them.

Applying cognitive policy analysis to the drug issue 237

It should be added that, while harm reduction was redefined in a more orthodox manner,it had almost disappeared from the agenda of the DoH Drug Policy Unit. There, a reducednumber of senior civil service managers had succeeded the heroic innovators of the 1980s.This, as well as the ‘‘unhealthy turn of British drug policy’’ (Stimson, 2000), prompted thelaunch of the Methadone alliance and the UK Harm Reduction Alliance. Among theirfounding members were key players who had successfully lobbied politicians and seniorcivil servants in the 1980s. That they had resort to outsiders’ public lobbying tacticscan be analysed as a further sign of the decline of harm reduction as an official policy.Among their causes for concern was the fear that the harm reduction legacy woulddisappear, including at the local level. There, as shall be seen, relative autonomy withregard to both the political arena and the guidelines and directives produced at thenational administrative and professional level had sometimes allowed for the long-termpreservation of secondary prevention measures. Depending on the type of agency andprofessionals or agency workers considered, this had entailed a less stigmatizing view ofdrug users.

The history of harm reduction policies at the local level

Both the lack of central co-ordination and the diversity of the local drug policies have beenunderlined (MacGregor, 1998, p. 134; Stimson & Lart, 1994). This was also demonstratedin a case study carried out in three London boroughs (Hudebine, 1998). As in some otherlocalities, the implementation of harm reduction measures, predated the national guidelinesand recommendations but a consensus on those was not easily reached (Cranfield,Feinman, Ferlie & Walter, 1994). The representatives of the social services of one boroughand the majority of the representatives of the psychiatrists working in the local DDUs (DrugDependency Units) were initially reluctant to condone the exchanges of syringes (1986–7).Their objections were that results in terms of prevention were not guaranteed and suchmeasures may encourage an increase in the drug use by rendering it more acceptable.The supporters of a fast implementation of secondary prevention measures were recruitedwithin the voluntary sector and found allies in the health co-ordinator of one borough andthen among local health managers and public health officers.A local consensus in favour of the development of harm reduction measures began

to emerge only after the publication of the evaluation of the pilot projects and theACMD report in the beginning of 1988, and persisted after 1993. The local health authorityand social services drug abuse co-ordinator asserted that, after the termination of thering-fenced subsidies aimed at the prevention of AIDS and drug abuse, the continuationof the local secondary prevention policies became a matter for local decision-making.While it had all but disappeared from the national policy agenda, public health officersconfirmed that local health managers still considered the prevention of AIDS amongdrug users as a chief priority, albeit in competition with other groups and under thecondition of a rationalization of the services involved. However, it should not be inferredfrom this case that harm reduction policies were necessarily developed and supported inthe same manner in other localities. After the local implementation of Tackling DrugsTogether in 1996 and the publication of the New Labour government anti-drug strategy,harm reduction still figured as a goal within the programme documents of the healthauthority.However, the agreement on the strategies of harm reduction was never exempt of

ambiguities and second thoughts. Underlying divergences persisted. This was exemplifiedby the reluctant co-operation of at least some of the DDUs. They were initially reluctant

238 H. Hudebine

to provide the local street agencies with the appropriatematerial: sterilized water, syringes etc.They showed no enthusiasm in accepting the clients referred by the local street agenciesand/or decided to provide them with abstinence based short-term methadone prescriptions.The reticence to offer long-term maintenance prescription was justified not only onthe grounds of costs but also by a dissatisfaction with the results of long-term methadonemaintenance.Cooperation was paradoxically more forthcoming from the police. Senior officers within

one local forum declared that they would not patrol in the immediate surroundings of thestreet agencies as early as 1987. Most of the agencies visited had established informalcontacts with the local police forces so as to avoid drug users being deterred from accessingthe agencies premises through fear of being arrested. Admittedly, these informal agreementsare subject to reversal and are often better understood by senior officers than by policemenpatrolling the street.Local initiatives launched under the auspices of the Home Office (Drug Prevention

Initiative, DPI) displayed the same proclivity towards the local preservation of harmreduction priorities. Whereas the DPI was initially aimed at the development of primaryprevention initiatives, the co-ordinator of the local Drug Prevention Team admitted thatthey often had to take into account the fact that the pupils targeted by their actionswould experiment with drugs in any case. They therefore delivered a more pragmaticmessage than what their brief would have allowed in theory.To account for the local promotion and long-term preservation of harm reduction

policies, it is possible to point at the existence of local public or community health culture.Namely, public health professionals, some doctors and voluntary organization workersdeeply adhere to the principle of socially equitable access to care and also believe itmakes both financial and public health sense (Hudebine, 2001). This translates at themicro-social level, that is to say when the social representation of drug users among front-line workers is considered and may have an impact in terms of de-stigmatization of drugusers also here again, street agencies and drug clinics sector differ in this respect.In street agencies, drug workers interviewed purported to consider drug users as individ-

uals, that is to say not as criminals (which is the alleged attitude of the police) or as sick per-sons (which is the alleged attitude of the DDUprofessionals).Minimal rules prohibiting druguse or dealing and violence were certainly established. However, the successful completion oftheir day-to-day tasks also involved a dual activity of negotiation and adjustment: with officialand organizational rules, on behalf of the drug users, and with the latter themselves.The first ‘negotiation with the rules’ sometimes took place when harm reduction mea-

sures were taken without prior authorization of management boards or health authorities.Later, although legally prohibited, possession of drugs had to be tolerated on the premisesif a contact with drug users was to be maintained. Negotiating with the rules also involveddiscussions with workers and officials acting in other agencies and organizations playing apart in the local drug field. Informal contacts and agreements with the police or negotiationswith social services were evoked. One objective was, for instance, that the rules regardingchild care allow for drug using parents to keep custody of their children more often, sothat they are not deterred to contact health and social services. Other examples involvednegotiations conducted on behalf of the drug users with probation and housing servicesas well as contacts with neighbourhood associations. All these factors point to the possibleexercise of discretion and the advocacy role of drug workers, with the aim to combat themarginalization of the drug users.The corollary of this advocacy role was a negotiation with the drug users themselves. This

was conducted along the line of the philosophy of harm reduction. It did not necessarily

Applying cognitive policy analysis to the drug issue 239

conform to the stated aims of the national drug control policies (especially concerningabstinence in the nineties) but generally concentrates on more achievable goals, such asnot sharing injecting material. Evaluation reports produced locally pointed at variationsin the type of relations established with drug users. Voluntary agencies aimed to adoptmore flexible approaches than the clinical sector and some appeared more ‘‘user-led ’’than others. In an agency founded initially as a self help group, drug workers reportedthat the dialogue with drug users is often underpinned by a view of their behaviour as a‘‘choice of lifestyle’’. Here again, beyond the public health priorities, the social inclusion(stabilization) ‘‘in a friendly atmosphere where they can feel at home’’ was the chief objectiveand, as in most of the other voluntary agencies, a picture not dissimilar to activity of theFrench social housing front-line workers seemed to emerge. However, it was confined tothe local and micro level and applied much less in the clinical sector.The view of drug users differed markedly in the clinical sector. DDU professionals

tended to view their clients, not necessarily as mentally ill, but as ‘‘people havingemotional problems, displaying symptoms of various sorts’’. In the period preceding theiracceptance of the principles of harm reduction, they would restrict the distribution ofclean syringes and long-term prescriptions to their older and more dependent clients.They were, before and after 1987–8, dissatisfied with the effects of long-term prescrip-tion on drug users. Building a trusting relationship with drug users appeared to beconceived as a difficult task. Psychiatrists had the feeling that if they appeared tocondone too overtly long-term prescription, they would be subjected to insistent anddifficult to resist demands from the drug users. It would then be difficult to adhereto proper medical procedures and there were risks that the methadone distributed onthe premises would spill over onto the black market. In addition, the psychiatristsinvolved in the DDUs appeared to devote less attention to the social circumstances oftheir clients than street agencies’ drug workers. It is worth pointing out that street agen-cies, although more professionally managed and reduced in numbers, still functionedalong the same lines in 2000.

Conclusion

This article has demonstrated that consensus and coherence, as defined in the cognitiveapproach, are the exception rather than the norm in British drug policy. Such a conclusionraises questions regarding both the explanation of stability and change in the policy processand its socio-political meaning, especially for drug users. As space is limited, only a fewhypotheses are evoked here.First, institutionalized ambiguity and relative autonomy of the levels of governance where

normative, cognitive or instrumental aspects are debated by the organizations and actorsinvolved, appear to be defining characteristics of the British drug policy style. Consensusor agreement may be reached at one given level, but often in ambiguous and/or contradic-tory terms. Ambiguity and ambivalence in agreement and decisions enable in turn authori-ties, organizations and actors in charge of the implementation of policies, guidelines andprocedures to interpret or even distort the cognitive framework(s) of drug policy accordingto their values or interests. Given the scope for successive and simultaneous ambiguousagreements and reinterpretations, it is therefore not surprising that local practice mayultimately differ markedly from the policy orientations set in political discourse. This andspecific local factors may help account for the survival of local harm reduction policies.There are, however, limits to the ability to implement ‘dissident’ policies on the ground.Namely, one should not appear publicly to contradict an official political line as was the

240 H. Hudebine

case of John Marks in Liverpool, which later brought a closure of his clinic where heroin wasprescribed (Henman, 1995).Given the above observations, it could help to understand drug policies as an exercise in

the ‘containment’ (Dorn & South, 1994, p. 294) of tensions (MacGregor, 1998) with a con-cern only for apparent coherence and consensus: balancing ambivalent priorities which, ifsimultaneously pursued will entail contradictions. Institutionalized ambiguity is essentialto this balancing act, but produces adverse effects. Enforcement involves a marginalizationof drug users (McDermott, 1992; MacGregor, 1999; South, 1998) while one of the statedpurposes of drug policy is to reduce the health effects of drug use and to encourage thesocial inclusion of drug users. If one chooses to understand this balancing act through apolitical cost/benefit analysis (Padioleau, 1982), then it becomes possible to make senseof the changes sparked by the arrival of HIV. Before the emergence of the epidemic,drug policies were incoherent, but manageable and practicable since they yielded politicalbenefits superior to their costs (adherence to international commitments; satisfaction ofperceived public opinion). Costs were high, but concentrated on a marginalized andunorganized minority with few open advocates. Admittedly, a more sizeable section ofthe population was (and still is) affected by drug-related crime. But, any increase indrug-related crime tends to provide an additional justification to drug enforcement policies,rather than undermine them. This does not imply that the actual health and social problemsof the drug users were not taken into account by the politicians. However, one can arguethat this could only be done provided that it would not contradict the political rhetoricabout drugs in a visible manner.The HIV epidemic had a potential to change the terms of this equation, by making the

costs of the marginalization of the drug users more visible, as well as politically and finan-cially more expensive. While it did not revolutionize the paradigm of the British drugpolicies or make it more coherent, it certainly brought a shift in the distribution of thecosts of its contradictions. Modest changes benefiting drug users were achieved, in spiteof the decline of harm reduction, at a political level and the shift back to a more orthodoxpolicy interpretation at the community level. Evidence for this hypothesis lies in the perpet-uation of local policies of harm reduction. These involved micro-social interactions andnegotiations with drug users, in a nonstigmatizing manner, and with the view to fostertheir social and health care rights. These are congruent with the ‘extended’ version of thecognitive model but still take place in a context characterized by deviantizing tendencies(Pearson, 1999), especially at the political and national policy level.It could nevertheless be said that drug users bear less of the costs of the ambivalence of

drug policies. Their health and social needs are (sometimes, in some localities and notothers) better taken into account. This has translated into the imposition of (admittedlylighter) costs on other sets of actors and organizations. For instance, the local healthauthority and social services studied had to extract resources from their general budgetsto cater for a previously neglected section of their population. Other less obvious examplesinclude members of the police forces and DDU psychiatrists. Both categories had to adjusttheir practices, more reluctantly in the second case with, in addition, the necessity toshare both resources and influence with other actors and organizations involved in thelocal drug policies.The picture of drug policy that has been drawn here could lead to a very British amend-

ment to the more continental cognitive approach which was initially strongly inspired byHabermas’ work. As has been seen in the beginning of this article, cognitive analysts puta strong emphasis on the centrality of shared norms and values in social integration, stabilityand political legitimization. The conclusions that could be derived from the above analysis

Applying cognitive policy analysis to the drug issue 241

seem to be much more in line with the thoughts of one of the staunchest British critiques ofthe German political philosopher. David Held’s definition of a society or political systemstability seems to apply very well to the drug policy case:‘‘Stability is related to the ‘decentring or fragmentation of culture (. . .)’. Fragmentation

acts as a barrier to a coherent conception of the social totality – the structure of socialpractices and possibilities. The political order is acknowledged not because it is regardedas ‘worthy’ but because of the adoption of an instrumental attitude towards it; compliancemost often comprises pragmatic acquiescence to the status quo’’ (Held, 1984).

Acknowledgement

The author is grateful for the financial help provided by the Agence Nationale de Recherchesur le Sida (ANRS) for this research.

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