The expert seminar “Innovative cocaine and poly drug abuse prevention programme”, organized by the Forum Droghe, took place in Florence, gathering over 30 people, mainly drug addiction professionals (clinicians or working in harm reduction programs); academics, researchers, NGO representatives. The seminar was introduced by a public presentation of the project, addressed to local and regional policy makers, Italian press and drug professionals from the whole region, in addition to foreign and Italian participants to the seminar. The general aim was to identify the main features of an innovative model of intervention, gathering suggestions from research on “controls” over drug use.

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A working paper, previously sent to participants to specify the topics of the seminar, was assumed as a guide to the discussion. The working paper is integral part of this report.

During the first session, research on “control” over drug use was introduced as well as the underlying social learning paradigm of drug use explanation, focused on drug, set, setting factors. Studies on controls over cocaine use were examined. This kind of studies also exists for different drugs and the control perspective may be adopted for any drug, either legal or illegal. For this reason, the discussion was not limited to controls over cocaine and stimulants, though focused on them. The peculiarities of research on “controls” were shown.In opposition to most studies, carried out among problem users in treatment, research on controls aims to gaining more insight into patterns of cocaine use in “natural” settings, among groups normally not associated with problematic drug consumption and not enrolled in drug addiction services. As a result, this kind of research avoids the “worst case” scenario of most intensive drug use (and the consequent medical emphasis on “risks” and “harms” of drug use). Research in natural settings suggests that the “escalation” career is relatively rare, while the most common trajectory of use is variable, with a trend towards moderation. Investigating users’ point of view and perception of controlled/uncontrolled use allows to identify “controls” as self imposed behaviours or rules that regulate the locations and the occasions of drug use, the suitable companions, the timing, the amount of substance, etc. These social controls and self regulation strategies represent the set and setting factors, that are able to explain the variability in drug use patterns and trajectories beyond the (immutable) pharmacological factor (drug) and its “addictive” properties .The drug, set, setting paradigm was analysed in opposition to the disease model, focused on chemical “addictive” properties of drugs. The disease (pharmacocentric) model is still dominant, in research as well as in drug addiction services practices.

The second session focused on how findings from research on controls fit with present practices in drug addiction services led by the disease model; and in particular, how self-regulation strategies are presently considered/ignored/challenged by professionals in drug addiction services. Significant differences were identified between users and drug addiction services perspectives, such as the different view on drug use careers. In the disease model a dichotomy is assumed in patterns of drug use and in typologies of drug users: either abstinent or addict; either controlled or uncontrolled use; either controlled users or uncontrolled users. In this perspective, “uncontrolled” users are believed to be (permanently) unableto step down from intensive to more moderate patterns of use and to maintain them over time, owing to their personal (biological/psychological) deficits. On the contrary, research in natural settings shows a continuum in drug use patterns and trajectories. Moreover, in the disease model the escalation trajectory is considered highly probable, owing to the addictive properties of drugs, while research on controls shows a general trend towards more moderate patterns of use.

The trend towards moderation can be explained through a learning process: from social context and from their own experience, users learn control over drug use by setting rules regarding the drug (the amount and/or the frequency of use); the set (for example: using when feeling well, not using when in a bad mood); the setting (for example: using with friends, not using when working). Main differences between the traditional model of intervention led by the disease paradigmand an innovative “self regulation” model (led by the “control”perspective over drug use) were outlined. They refer to areas of change: while the former focuses on drug use, the latter keeps broader fields in sight, concerning set and setting; to choice of goalsof interventions in the drug area: the former focuses on abstinence only, while the latter includes stepping down; to role of services and resolution pathways: the former ignores natural recovery and assumes treatment as the only pathway to resolution, while the latter takes suggestions from natural recovery and “natural” self regulation abilities; to users/professionals relationship: in the former, users are expectedto admit their powerlessness over drug use, while in the latter professionals are supposed to support users’ expectancies and beliefs in self control over drug use. The users/professionals relationship was also examined inclinical settings. “Clinicians cannot decide in place of patients” is a consolidated tenet in clinical activity.

Nevertheless, this principle is largely neglected in the field of drug use. The traditional view of addicts’ loss of control and powerlessness over drugs was criticised in the light of the most innovative psychological Health models. Even in medicine, for patients affected by serious organic diseases, a positive approach is widely adopted. Prevention, focused on avoiding risks related to unsuitable behaviours (developed within the medical model) is being replaced by a proactive approach, focused on choice (of goals and behaviours), on process (step by step), on promoting “positive identities”. Patients’ abilities and expertise in self-management are emphasized. Nevertheless, self- management still appears as an awkward concept in the field of drugs, andit is only accepted when finalized to abstinence. Once again, the shift to innovative approaches is a challenge in the field of drug use, for the lasting influence of both the disease and the moral models. As a consequence, a wider perspective into health models and psychosocial constructs is essential, to get rid of the moralistic perspective on drugs. A blueprint for an innovative operational model was drafted at the end of the second session.

The third session dealt with the control perspective and its impact on drug policies, harm reduction policies in particular. Prohibition stems from the traditional social representation of “powerless” users “under the influence” of harmful addictive properties of drugs. Users are assumed not to be able to “tame” drugs through social/informal controls. As a result, legal controls remain the only chance to keep drugs at bay. On the contrary, research on controlled use, as discussed in the first session, shows informal/social controls do exist both for legal and illegal drugs: informal controls (rituals and social prescriptions) shape cultures of “safer use”, that sustain individuals in developing control over (the risky chemical properties of) drugs. But legal controls (i.e. prohibitionist legislations aimed at eliminating drug availability and drug use) do not allow rules of safer use to circulate widely into the mainstream culture. Moreover, most legal systems work to destroy conditions for individual drug use control (through the risks of illegal markets, the threat of criminal prosecution, marginalization and discrimination). Shifting to a different social representation of users as capable to be “over the influence” (of drugs) may have a relevant impact on drug policies.

Harm reduction, as analternative to the traditional paradigm focused on elimination of drug availability and drug use, may be the policy framework where the control perspective can find its proper place. To this purpose, Harm Reduction is to be seen as a comprehensive drug policy approach aimed at sustaining cultures of safer controlled use, to support individuals in developing their own self regulation mechanisms: an innovative paradigm in place of both the moral and the disease paradigms. Harm Reduction has since been consideredas a pragmatic set of interventions for users “unwilling or unable to achieve abstinence”: a sort of “ancillary” drug policy pillar, to be implemented in addition to the other traditional pillars (law enforcement, prevention, treatment). In other words, Harm Reduction has been developed within the disease model, not as an alternative to it. Such is the case for Methadone Maintenance programs, developed in the fatalistic view of addiction as a “long term chronic relapsing illness”. Even more significant is the case for decriminalisation of drug use, based on providing “therapy in place of punishment”, from the assumption “users are not criminals but ill people”. Decriminalisation and Harm Reduction have worked hand in hand, and Harm Reduction has facilitated the shift from the “crime” to the “illness” paradigm. The pitfalls of the disease model in the field of drug policies were thoroughly examined.