Substance use problems are seen as the domain of younger age groups. However, recent trends in drug use and the demand for drug treatment show an increasing prevalence among older adults. Over the next twenty years it is anticipated that the number of older substance users will increase. It is therefore becoming more important to understand the compound challenges faced by older adults who use class A drugs. The research questions for this study are: What are the illegal drug use behaviours and social circumstances of adult class A drug users over 50 in England? and How and why do they use class A drugs? To answer these questions a constructivist grounded theory methodology was adopted. Semi-structured, face-to-face interviews were conducted with 30 (24 men and six women) participants, over 50 years old, living in England. All participants had used a class A drug in the last month. The results showed a heterogeneity of social circumstances among the sample. For the majority of the participants their drug use was highly dynamic - frequently managed in line with their circumstances. These participants also adapted their drug use in line with their awareness of their changing physical vulnerability. For others however, their drug use was fixed and linear. All participants’ drug use is described by the major category ‘managing lifestyle’. Participants were using drugs to change the way they felt - described by the major category ‘altering feelings’. The data also suggested an apparent interaction between how and why these participants were using drugs. A model of drug use in older adults was developed from the fourteen major categories - underpinned by the core category ‘achieving balance’. It describes a process of ongoing balancing, influenced and informed by the participants’ experiences of the past and expectations of the future.

This thesis explores how non-qualified ex-user and carer drug workers have made the transition from alcohol and drug use to paid employment in the substance misuse field. The key aims of the research were to:  explore issues that affect the transition experiences of ex-users, carers, peer mentors, students, and paid workers;  examine influencing factors that determine ex-users’ and carers’ decisions to disclose or not their background to colleagues and service users at different stages of their transition;  explore how ex-users perceive their identity, or feel themselves to be perceived, within the context of the substance misuse field;  understand how non-qualified, ex-user or carer drug workers make the transition from service user to paid employee in the substance misuse field, in order to facilitate greater understanding of their experiences in becoming and developing as drug practitioners; and  make recommendations regarding training, employment, and staff development for my own organisation; to enhance my own practice; and to influence wider policy and practice principles. Most ex-user narratives already available ‘end’ at the point where treatment ends leaving much to be discovered regarding what happens next. Understanding the next stage of transition journeys will be valuable in enhancing recovery and treatment outcomes; and determining how best to recruit, induct, train, supervise and support ex-user drug workers in gaining paid employment within the substance misuse field. As a practitioner-researcher I adopted a narrative approach to gain insight into substance misuse practitioners’ experiences, perceptions and attitudes. Participants were recruited through a service user-designed questionnaire and 11 non-qualified ex-users/carers identified themselves as willing to participate in narrative interviews to share their journey of becoming practitioners (consent forms were used and identifying information anonymised through pseudonyms). I used process-mapping to develop participant-structured narratives, so that each participant ‘plotted’ key events along their journey (chronologically) while telling their story. I asked questions to clarify and gain insight into their self-identified significant events over two interviews, each lasting 1-2 hours. From these narratives and process-maps, I identified and analysed three orientations: transition, disclosure and professional identity. Key transition findings included the influence of key-workers in encouraging clients to become drug workers; difficulties, barriers, expectations and opportunities; and motivation to become drug workers (for example, ‘giving something back’, status and remuneration). The findings suggest that participants based disclosure decisions on previous experiences, that is, positive responses were more likely to result in future disclosures; there was limited (if any) guidance available to volunteers and staff; and disclosure was viewed as an individual, selective decision. In terms of professional identity, the findings highlighted different perceptions of what it meant to be a professional; the role boundaries, qualifications and status play in determining professional identity; and tensions between ‘textbook’ and ‘ex-user’ drug workers. A number of recommendations were identified, focusing on how ex-drug users can be better trained and supported in making the transition to substance misuse practitioner. The recommendations not only consider factors such as education and volunteering but, more specifically, how to utilise disclosure effectively and safely; inter-professional working; ex-user and carer motivation; and personal and professional boundaries.

Cannabis continues to be the most widely used illicit drug, usually used recreationally without significant problems occurring. Concerns remain over long term health of users and the possibility of associations with mental illness. Surveys suggest regular use remains common amongst teenage males, taking place concurrently with the period when teenagers are engaged in identity development and making the transition to adult life. The thesis is based on qualitative interviews and ethnographic observation of two cohorts of male teenagers and interviews with a group in their late twenties reflecting on their teenage use. Methods and analysis draw pragmatically on ethnography and grounded theory, developing interpretations inductively before moving to relate the concepts generated to existing theory. Cannabis was smoked predominantly in the context of an extended social group. While the majority reported enjoying the effects of cannabis, smoking with this group was particularly valued for the social contexts it facilitated and maintained. Within these groups three orientations to use were observed differentiated by individuals level of commitment to cannabis, and their understanding of the functions of use. The teenagers saw cannabis use as a transitory phase which they expected to cease as adult roles were acquired, though this was considered a difficult and potentially protracted process. Adapting to an unchosen extended adolescence involved maintaining proxy roles, in which nascent aspects of identities could be expressed and developed. Social roles and relationships acted as a containers for the display and reflection of aspects of identity. The group provided a non-contingent context allowing for identity exploration, play and development. The contingency of closer ongoing familial and social roles limited opportunities for such exploration. Previous identity research has stressed close contingent relationships, the analysis suggests several mechanisms relating cannabis use to the importance of non-contingent relationships in times of identity transition.

The Foucault influenced Opium and the People (1981) has generated considerable interest in its dealing with the construction of the medico-legal persona of the addict and has come to dominate many different interdisciplinary areas of study. An important critique of this work can be found in Henry Bryan Spear’s response to criticisms of civil servant Sir Malcolm Delevigne. These points reveal the operation of the repressive hypothesis in drugs discourse. The limitations of Opium and the People call for a fuller genealogical analysis of the subject of addiction. Discipline and Punish (1991a) and History of Sexuality Part One (1998) are the publications closely associated with the genealogical period of Foucault’s thought. The earlier publication of History of Madness (2006a) and Foucault’s lecture series also enable further interesting insights into the hermeneutics of addiction. One minor area for Opium and the People is the emergence of injection drug use and this phenomenon represents the focus of this thesis. It is through the story of the hypodermic syringe that we can see with more detail how the hermeneutic processes that were intended to eradicate opium use for pleasure ultimately led to the spread of intravenous injection. Beginning with the structural elision of the pain controlling from the pleasure producing elements of opium we can see the unexpected consequences of utopianism in the form of an outbreak of intravenous knowledge in the 1920s New York City following the imposition of a total prohibition on opiates. Through the tale of the hypodermic we can see the creation of the modern day ‘Tom Thumb horror’, the influence of confessional technology and the importance of resistance to bio-technico power in the creation of the phenomenon of intravenous injection drug use. In Part One: ‘Self and Truths’ I outline the methodological project, the role of Friedrich Nietzsche’s thought upon Foucault’s idea of history. Here we will establish the core elements of Foucault’s genealogical method with a specific emphasis on the importance of the repressive hypothesis as outlined in The History of Sexuality Part One (1998) for the creation of the pejorative archetype of the junkie. In Part Two: ‘Structure, Monsters and Poets’ the importance of Descartes’ thought on the experimental enquiry into the control of pain are considered along with the inability to include the euphoria that opium induces. The importance of the History of Madness (2006a) is developed in this section as a key problem in our comprehension of the prohibitive response to the pleasures that are associated with opium. This section considers the importance of juridical process in the creation of the ‘Tom Thumb horror’, a process whereby legal case law is linked to broader medical and legal processes, thus enabling the creation of medico-legal persona that are related to specific jurisprudence. The importance of the creation of the idea of inebriety and the link developed between opium and alcohol enables us to observe this ongoing process. I consider the role of Thomas DeQuincey and Samuel Taylor Coleridge in the creation of the opium eater and the mysterious process whereby these musings became established as legal and medical facts. The significance of DeQuincey’s Stoic method of introspection and its impact on the creation of a new medical condition is developed. In Part Three: ‘The Needle, Inebriety and Resistance’, I explore the invention of the hypodermic and its spread across the globe. I look at the ongoing legal process that led to the abolition and the creation of an industry around a new medico-legal identity of the opium eater. The decline of the opium trade and the eventual prohibition are set against a paradoxical response of a small proportion of opium users that provides clear empirical evidence of a phenomenon that Foucault termed resistance. The importance of the relationship between hermeneutics, public policy and resistance in the creation of the conditions that led to the spread of the knowledge of intravenous injection forms the basis of the main conclusion of this study. In the final section I explore the implications of this study in the present-day and consider a Cynic alternative to the Stoic view of opium addiction.

Contemporary approaches to the treatment of problematic drug use situate the individual within a complex system of power-relations. This system of power-relations operates through a wide range of experts, techniques, strategies, institutions and subjectivities. The objective of this PhD research project has been to understand the complexity of these power-relations, how they operate and the effects of their deployment. In many ways, this task has involved problematising some of drug treatment’s most basic and taken-for-granted concepts, such as heroin withdrawal. This thesis adopted a Foucauldian genealogical approach. The discourses of natural recovery and recovery capital, needle fixation and withdrawal were identified and then subjected to a genealogical investigation and critique. This historical excavation opened up a wider discursive field and theoretical interest in the productive effects of a poisoning rationality and dividing practice on the body and population. This then informed a second genealogical investigation and critique. In conclusion, this thesis argues that through subtle and intriguing means, the population, body and subjectivity of the drug user have become the objects of a multifaceted set of discursive and non-discursive practices that extend beyond the institutional boundaries of the drug treatment system and into the life of the individual drug user. These practices have focused upon various domains including health and illness, disease, criminal behaviour, relations with other drug users and non-drug users, education and employment and other behaviours deemed problematic. These practices, and the truths that are dependant upon them, this thesis will argue, have been formed and reconfigured by conditions that are historically contingent and dependent upon various social, scientific, cultural and political influences for their existence.

This thesis introduces a novel and alternative way of understanding paan addiction among Bangladeshi women by exploring their lived experiences. There is growing medical evidence that paan, a mixture of betel leaf, areca nut, tobacco and white lime, is injurious to health, causing cancer, oral disease and addition (WHO, 2004). Paan use is prevalent and visible among the Bangladeshi community in East London. However, paan dependence is principally examined through the dominant medical model, which prioritises the scientific and pharmacological aspects. Research has yet to examine paan dependence from the user's perspective, which limits health and social care professionals from understanding the practice, the determinants of the habit and the elements contributing to its continued use. Understanding the user perspective would assist in designing and delivering appropriate and targeted interventions. There are no similar studies of this nature into paan use and therefore this study developed a theoretical framework by examining literature pertaining to migration, biographies and inequalities in health. METHOD: An ethnographic study was conducted and data collected through extensive fieldwork followed by in-depth interviews with thirty Bangladeshi women in Tower Hamlets, East London, who have continuously used paan over a number of years. Participants were recruited through purposive sampling. Interview data was analysed thematically using grounded theory techniques (Glazer and Strauss, 1967) and then triangulated to compare and crosscheck the consistency of the research findings. FINDINGS: Key research findings indicate that while health discourses have explained paan use simply as a result of physical addition to tobacco, exploring the biographical, historical and social context of paan use developed a deeper understanding of how the participants constituted the experience and meaning of paan addiction. Four key themes emerged - physical and psychological addiction, availability and social acceptance of paan chewing, lack of involvement in the wider social environment and 'Sylhetisation', (a concept introduced by this thesis to describe how the Bangladeshi community have created an environment similar to that of Sylhet). The main recommendation is that an understanding of the sociocultural aspects of paan use may help greatly in developing more culturally specific paan cessation strategies within tobacco policies.

Substance misuse and addictions impose serious health and socio-economic consequences for both individuals and societies. Substance use during adolescence predicts the severity of addictions in later life, indicating that adolescence is an important milestone for developing addictions. Alcohol and tobacco are the most common form of substance use in adolescents. The heritability estimates of alcohol and tobacco addictions range between 30-70%, suggesting that both genetic and environmental factors could contribute to the risks of addictions. This PhD thesis aimed to identify the genetic and epigenetic factors in alcohol and tobacco misuse in adolescence. The impact of life stress and circadian system on reward sensitivity and substance use was investigated in over 2000 adolescents from the IMAGEN Study. In the first study, both negative life events and ventral striatal activations during reward anticipation were shown to predict the increased alcohol and tobacco use in adolescents. The second study investigated the relationships among reward sensitivity, substance use and the DNA methylation in PERIOD 1, a circadian gene that was found to associate with stress-mediated alcohol use in adolescence (Dong et al., 2011). The third study explored the additive genetic and polygenic effects of single nucleotide polymorphisms (SNPs) in the stress and circadian systems on reward sensitivity and substance use. Results from the second and the third studies showed that reward sensitivity, alcohol and tobacco use in adolescents were not associated with the DNA methylation in PERIOD 1, and the genetic polymorphisms within the stress and circadian systems. The fourth study examined the genetic influence of stress systems on alcohol misuse. SNP rs1409837 on FYN oncogene related to SRC (FYN) gene was found to associate with the reduced drunkenness and binge drinking in adolescents at age 16. When investigating the role of FYN rs1409837 on brain functions, FYN rs1409837 was found to associate with the reduced amygdala activations during angry face processing. This thesis highlights the genetic influence of life stress on alcohol misuse and provides new approaches that should aid the understanding of genetic underpinnings of substance misuse in adolescence.

Substance Use Disorders (SUDs), are generally viewed as disorders of maladaptive reward memory and motivation. In SUDs, memories formed during drug use associate environmental stimuli with the rewarding effects of drugs. These stimuli can subsequently trigger craving, highly motivated drug-seeking and relapse, even after years of abstinence. An exciting new approach to combatting these maladaptive memories is via reconsolidation, the process by which memories become briefly unstable upon recall in order to strengthen or update before restabilising. In Chapter 1, I review reward memory mechanisms in SUDs along with pharmacological and behavioural determinants of memory reconsolidation to identify potential drug targets for interfering with reconsolidation. In Chapter 2, I use meta-analysis to assess the effects of two classes of drugs; N-methyl D-aspartate (NMDAR) antagonists and β-Blockers on blocking reconsolidation of reward memory in rats and show that NMDAR antagonism is far more effective. Building on this knowledge, in Chapter 3, I show that 10mg of the NMDAR antagonist memantine in combination with the retrieval of smoking cue-drug memory does not affect relapse or craving in a group of quitting smokers. As this null finding may have represented either a failure to destabilise memories or inefficacy of memantine, in Chapter 4 I use a reward conditioning paradigm in hazardous drinkers to show that NMDAR antagonist Nitrous Oxide can interfere with reconsolidation of cue-alcohol memory, when administered after a reminder of learning that induces a negative prediction error. Chapter 5 builds on emerging evidence of the necessity of prediction error to destabilise memory, using guided expectancy violation to destabilise naturalistic cue-alcohol memories in hazardous drinkers. Subsequent disgust counterconditioning updated these memories, reducing motivational salience and liking of alcohol stimuli, with associated reduction in drinking. In Chapter 6 I discuss the research reported and suggest directions for further study.

No description available.

There is a substantial body of evidence showing that substance use is associated with mental health problems, but establishing whether associations are causal and whether specific substances have independent effects is more challenging. The studies in this thesis aimed to investigate whether cannabis and cigarette use are associated with psychotic experiences, depression and anxiety, and examine the extent to which associations might be due to confounding, bias and reverse causation. Data used were from ALSPAC, a large longitudinal birth cohort. For most analyses exposure measures were assessed when participants were aged 16 years, and outcome measures at 18 years. Regression models were used to assess associations before and after adjustment for a large variety of potential confounders. Multiple imputation was used to try and account for potential attrition bias. A Mendelian randomisation approach was used to assess whether associations between smoking and psychotic experiences are likely to be causal, using SNP rsl051730 as an instrumental variable. Cannabis and cigarette use were associated with all mental health outcomes in unadjusted analyses. Adjustment for pre-birth and childhood confounding made little difference to most analyses. Adjustment for other substance use led to substantial attenuation in many of the analyses investigated. Although there appeared to be some divergence between the effects of different substances on specific outcomes, and differences in the specific effects of substances between outcomes, this was not supported by statistical evidence. There was no evidence to support reverse causation. The Mendelian randomisation analysis did not provide evidence of a causal association between smoking and psychotic experiences, but was underpowered. The findings are consistent with previous literature from longitudinal studies that show associations between both cannabis and cigarette use with incident mental health outcomes, but also indicate that unmeasured confounding likely affects most studies to date. At present there is not enough evidence to be confident that associations between substance use and mental health are causal. Future research should utilise novel methods to approach these questions from multiple angles in order to progress the field.