Friday, 15 March 2019

Can we build a more trusting, collaborative substance misuse treatment sector?

I spent Friday in Manchester, at EXCO2019 – the annual conference of the Expert Faculty on Commissioning.  There were lots of fascinating discussions throughout the day, and I’d recommend catching up by looking at the hashtag on Twitter: #EXCO2019.

One of the key issues revolved around balancing ‘dusting off the old vinyl’ and doing the basics well on the one hand, with the bright shiny disco ball of ‘innovation’ on the other.  Pete Burkinshaw from PHE kicked us off with this metaphor, but pretty much everyone else used it thereafter – in fact Kate Hall had already independently written it into her presentation!

As Tony Mercer from PHE suggested (echoed by Paul Musgrave later, who hadn’t heard Tony), we might sit down at home and listen to vinyl, but it doesn’t work everywhere: you might play CDs in your car and listen to MP3s on the train.

And this was the other key theme of the conference: tailored, or personalised treatment.  There’s an idea that I’ve written about before that although we hope tailored, segmented, personalised treatment will be efficient as well as effective and fair, but we shouldn’t take this for granted.  Fordism, where every colour is available so long as it’s black, sometimes has its place.  The devil, as ever, is in the detail, and the risk with this conference (as with most others) is that it becomes a sequence of platitudes, soundbites and metaphors without taking us forward in practice.

There was much discussion of ‘optimal’ dosing, defined as 60mls-120mls of methadone per day, or equivalent.  But Kerrie Hudson had earlier noted that, for her, being able to deal with cravings in the morning with a relatively low dose of methadone (say 30mls) and then use at other times, was a stabilising factor, meaning she could carry on working.  It was appropriate for her particular situation at that particular time.

The sensible way through this is to point out that (a) the patterns of prescribing in our system don’t suggest that most people on 30mls are ‘optimised’ even by their own definition, and the actual dosage of medication someone receives shouldn’t be imposed (whether that’s through an increase or reduction); it should be a joint decision between clinician and patient to achieve a jointly agreed aim.

And that kind of approach, along with all sorts of other initiatives that could be badged as ‘innovative’ or involving ‘segmentation’ were discussed on the day.  But they remain that: isolated examples of good practice.  We don’t (yet) have a tool for segmentation that could structure these kinds of conversations that keyworkers need to have.

In the session I participated in, I had been asked to introduce a discussion of depot buprenorphine – a fact possibly not unrelated to the fact the conference was made possible by funding from Camurus, who make these devices.

I don’t object to this, though the Faculty needs to be careful not to become reliant on one source of funding, and I think local authority contributions would be more appropriate.  I saw my role as being to ask some challenging questions and bring the conversation back to those practical considerations, rather than thinking the innovation will be useful in itself.  Who will this form of medication benefit?  Where could it be implemented effectively and efficiently, given we’re living in tough times financially?

I’m not sure I got my point across, but it didn’t matter anyway, because the discussion, thanks to much more eloquent and passionate commissioners than me, took a turn to be about commissioning and the ‘sector’ in general.

This was where the conversation got interesting.  We talked about how certain metrics and processes, previously centrally imposed (like TOPs and ‘successful completions’) don’t have to be at the heart of local authority commissioning, but the point was made that this doesn’t mean agencies and staff can disregard them even if they wanted to.

As a provider, you can’t be sure that if your successful completions are low in one area because you’re being honest and retaining people in treatment, that you won’t be judged unfavourably when you tender for a contract in another area.  Not all commissioners take this view.

And as a member of staff, if you stop recording people (sometimes optimistically) as successfully completed, or don’t note that they have apparently stopped using on top or committing crime on their latest TOP form, then perhaps you’ll lose a sense of a job well done.  And how will the service user themselves be able to identify that they’re making progress?

It’s not as straightforward as a commissioner just telling a provider to relax about metrics.

And what about length of contracts?  There was agreement that long contracts were a good idea, and local authorities seem to be increasingly open to these.  But it’s not the case everywhere, and the sector still feels competitive.

Nurses leave to work elsewhere in the NHS because there just isn’t (felt to be) the same security in substance misuse.  Locally, in each of the three acute hospitals across Dorset there’s at least one nurse in the alcohol liaison/care team that used to work in the Dorset substance misuse service, and we can’t seem to recruit replacements.

Organisations feel they can’t reveal their ‘trade secrets’ (and if anyone has indeed got the ‘solution’ to ‘addiction’ there certainly keeping it secret), and the spectre of tendering can lead to tensions, fear and anger on the ground.  It’s hard to believe that doesn’t then seep into consultations, affecting service user care.

And this isn’t the fault of those frontline staff or the organisations that employ them.  It’s central and local government that have created and maintained these competitive structures.  And while some people in the room could be congratulated on creating different approaches in their area, this doesn’t change the overall picture or culture as being one of competition and sometimes open confrontation.

So I started to think about how, in practice we could make this change.  And all the themes we’d been discussing seemed to coalesce.  We don’t have clear segmentation tools.  Guidance on ‘good practice’ tends to be relatively abstract (NICE, Orange Book) or just a set of examples designed to show that local government is brilliant (the Local Government Association).  Approaches to performance management vary considerably.  Contract lengths vary wildly from 3 years to 10 or more.

This lack of consistency makes life difficult for providers, who can’t tailor their approach to one commissioner, and commissioners, who end up reinventing the wheel.

Last year, I wrote about how I could see a role for the Expert Faculty as a repository for genuine, practical examples of ‘good practice’, but this would need to be distinct from the work of PHE or the LGA.  Some of the work that could improve the situation is being coordinated by PHE through their review of opiate substitution treatment, which I’m hoping will produce some practical guidance on segmentation, enabling frontline workers to put the ‘phasing and layering’ of treatment proposed by the Medications in Recovery report into real-life practice in a straightforward way.

But there’s more that needs to be done to reshape the sector and build trust.  One thing I wondered aloud about in the session of the conference I was directly involved in was something like a charter or a kitemark for commissioning.

Providers want to feel confident they’re entering into an arrangement with someone who’s reasonable, flexible and constructive, and where they don’t have to worry about misleading metrics.

And commissioners, I’m sure, would embrace a set of principles – particularly if they could take these to elected members or senior management and explain that these (for example not re-procuring every 3 years) are considered good (or even standard) practice in the field.

I’m not going to talk much more about this here, as it’s only the most embryonic of ideas (and I wouldn’t claim that it’s original) but I wonder if it’s worth exploring further.  It would surely give both commissioners and providers the confidence to break free from the shackles of successful completion metrics and 3-year tendering cycles that occupied so much time and prompted so many sighs over the course of the day.

I often ask for comments on this blog, and rarely get any, despite hundreds of people reading it, supposedly, so I’m not expecting a great debate in the comments.  What I hope, though, is that by EXCO2020 we’ll have a clearer sense of the practical, tangible contribution of the Faculty, and whether this sort of initiative is what it should be championing.

Wednesday, 13 March 2019

Consultations on drug policy

A couple of days ago, I was asked by email for some comments on the current health and social care select committee (HSCC) inquiry and Black report consultations on drug policy.  Tonight, on my own time, I drafted some thoughts.  I've copied these below and would welcome comments.

Just to give some context, the questions in the Black report at this point are as follows:

·       What are the demographics and characteristics of drug users and drug suppliers and how have they changed?

·       What causes individuals to become involved in drug use and/or drug supply?

·       What are the evidence-based approaches to preventing and reducing drug use and drug supply?

·       What causes drug related serious violence and how can it be prevented?

·       What are the most important evidence gaps relating to drug use and drug supply and what further work would be needed to address them?

And those for the HSCC inquiry are:

Health and harms:   

  • What is the extent of health harms resulting from drug use?  

Prevention and early intervention:   

  • What are the reasons for both the initial and the continued, sustained use of drugs? This refers to the wide spectrum of use, from high-risk use to the normalisation of recreational use. 
  • How effective and evidence-based are strategies for prevention and early intervention in managing and countering the drivers of use? This includes whether a whole-system approach is taken. 

Treatment and harm reduction:  

  • How effective and evidence-based is treatment provision? This refers to both healthcare services and wider agencies, and the extent to which joined-up care pathways operate. 
  • Is policy is sufficiently geared towards treatment? This includes the extent to which health is prioritised, in the context of the Government’s criminal justice-led approach.  
Best practice: 

  • What would a high-quality, evidence-based response to drugs look like? 
  • What responses to drugs internationally stand out as particularly innovative and / or relevant, and what evidence is there of impact in these cases? 
If you want to respond yourself - and I think this is something everyone with an interest should get involved in - the HSCC consultation closes on Monday.

So here goes my response.  I should point out it's not a formal response; just some thoughts that have occurred to me over a glass of my favourite intoxicant.


Having read through this, I think the fundamental questions are relatively similar, so here’s my stream of consciousness, which reflects the views of an academic rather than a commissioner.

Most drugs in themselves carry relatively low risk to the individual concerned when used in known dosages and purity, under safe conditions without forming patterns of substance use disorders.  Therefore the health harms resulting from drug use per se are relatively low.  Issues are most likely to arise when purity and dosage are unknown and where people have poor information about how to use more safely (or do not act on this information, sometimes due to the stigma or fear associated with the illegality of certain substances).

People come to use drugs initially due to a mixture of factors, with (anticipated) pleasure of some kind linked to availability.  What people find exciting, comfortable or pleasurable varies, and the effects of different drugs varies and is affected by setting, and so the reasons are as varied as people who use drugs themselves.  In understanding why people continue to use drugs, a functional approach is helpful: these substances serve a function for the people who use them, whether that is to have new experiences (‘psychonauts’), distance oneself from previous experiences or thoughts, or simply experience a ‘rush’.

For most people, trauma and poverty / lack of opportunities drive people towards problematic drug use and dealing.  Those involved in dealing are getting younger.  The violence associated with the drug market is the consequence of the substances being illegal, and violence increases when a gap in the market appears – i.e. when existing, stable dealers are arrested and imprisoned.

(But I understand the Black review has been instructed not to consider the legal status of drugs.  And in any case, the police will be more expert than me on this.  I hope Neil Woods from LEAP will be submitting evidence.)

Prevention of pursuit of intoxication and use of psychoactive substances per se is a somewhat futile task.  All societies, to our knowledge, have made some use of intoxicants or intoxicating practices.

Evidence suggests that the most effective approaches to prevent harm from substance use is not to focus on substance use or dispense information and advice, but to educate young people in relation to decision-making and safekeeping strategies, and to discuss these issues with adults in terms of the effects on their wider lives (e.g. improving parenting skills).  Such work should be integrated into broader process/practices, e.g. mainstream education, general healthcare and social work practice.

In terms of treatment, while there is relatively strong evidence that high-quality treatment and harm reduction initiatives can reduce crime and reduce the transmission of blood-borne viruses, there is a lack of evidence regarding ‘what works’ in fostering long-term recovery.  Therefore a priority for government should be to commission and support research that takes a robust, longitudinal approach to evaluate different treatment options and approaches in terms of their effectiveness.

As to whether currently commissioned treatment services are provided in line with this evidence, there are questions to be asked as to whether services engage enough people to make a difference at a population level, and whether, once people are engaged, they receive treatment in line with this evidence, much of which is based on either lab-style settings in terms of talking therapies, or US-style ‘methadone clinics’ in relation to opiate substitution treatment (OST).  What evidence there is suggests that dosages of medication dispensed as part of OST are not generally in line with evidence, supervision regimes are not applied consistently, and talking therapies are not delivered in line with tight guidelines.  In most cases there is certainly not joined up health and social care provision for the client group who have run into issues with substances, with services commissioned and provided by separate organisations, operating to different priorities and policies, and using different IT systems.

This is not to say that services are not appropriate and effective, given the limited nature of the evidence base.

The biggest challenge to delivering quality services is currently capacity.

Treatment services have been more than decimated in recent years, with cuts in most areas of at least 20% to budgets since 2013, and prevention work has become patchy and hard to monitor with the change how schools are overseen.  At the same time, resources expending on addressing the supply of drug use, for example through ‘county lines’, have increased in areas such as Dorset.  This is currently a ‘zero sum game’, and therefore it would appear that resources are being focused at less effective points in people’s lives, given that we know treatment can help reduce the burden problematic drug use and associated acquisitive crime can place on the criminal justice system.

A high-quality, evidence-based response to ‘drugs’ would be regulate all substances and therefore permit use that is in line with good harm reduction advice: i.e. where people can know and control the dosage and purity of the substance, and the manner in which they ingest their preferred intoxicant.  There would be more accessible treatment, better integrated with different elements of the health and social care system, a better evidence base by which to judge the performance of this system, and more resources to support the oversight of the system in relation to quality.

As for international comparisons, no country has this cracked, partly because opportunities for innovation are hampered by international treaties and the position of the UN and particularly the USA.  In general, we know that harm is not simply determined by a country’s regulatory or treatment system, as confirmed by the Home Office report a few years ago.  Each country should take a tailored approach to each substance, based on its history and starting point today.  Social and cultural context play a key role in determining problems and appropriate solutions – just look at trends and approaches to alcohol use in different countries around the world.  An approach that is perfectly reasonable and successful in one context can be destructive in another.  However, to focus on specifics, the approaches adopted by Uruguay and Canada for cannabis seem to me the best models for effective regulation introduced so far, though they will need careful monitoring to evaluate their impact, particularly in comparison with the various alternative regimes in operation across the US.  These initiatives could and should go further, however, and cover all intoxicating substances – though with regimes tailored to the particular risks associated with each drug.

As you’ve probably guessed, I’m writing this on my own time, as it may not be what you were looking for!



This morning I was asked why I hadn't mentioned Portugal, and whether this would be a good idea.

This was my response:

Personally, I think we're not far off the Portugal model in the UK, with treatment offered for most people who commit drug-related acquisitive crime and very few people (in the grand scheme of things) imprisoned for possession. The greatest harms (DRDs, child exploitation, cuckooing) wouldn't be solved by decriminalisation, but only legalisation.

But you're right that it at least reflects an achievable step, and highlighting it could convince people that change is possible.

Friday, 11 January 2019

The downside of Dry January

I’ve been thinking about Dry January a lot recently.  Well, it is January.  And like every year, there’s been lots of views aired by journalists and professionals.

As usual on this issue, the person who comes closest to representing my views is Ian Hamilton.  He’s argued that while Dry January undoubtedly delivers some real positive change for many drinkers, it’s less clear whether it’s effective for the people who genuinely need to change their drinking behaviour, and it certainly isn’t designed for dependent drinkers.  He even worries that it could benefit the alcohol industry, as it distracts from those with more serious problems – who provide the bulk of the industry’s revenue.

I should start with a caveat I don’t think we make explicit often enough in discussions about alcohol policy.  People come with a personal agenda.  I like drinking, and I like getting drunk.  As far as I am aware (and that’s a very important point), this has very rarely had any impact on my professional or personal life, and certainly not in a very long time.  I like to think I’m pretty self-aware regarding alcohol, and so I’m pretty good at planning any drinking occasion so it doesn’t impact on other obligations.

I don’t have any problem admitting this enjoyment of drinking and drunkenness, and I certainly don’t see it as any kind of weakness or moral failing.

This fact that I enjoy drinking, and specifically the feeling of intoxication, is important.  Often, those who advocate abstinence either don’t understand the attraction of drunkenness, or, when they do acknowledge this, see it as somehow a less respectable or worthwhile pleasure than, say, reading a book or doing yoga.  I just can’t sign up to that idea of higher and lower pleasures, and would emphasise that a case can be made that drug-induced pleasure is in fact the ‘purest’ kind of pleasure possible in a Kantian sense (modified by Bourdieu), as it’s not instrumental or tied to pretentiousness; it’s a pleasure (for some people) simply in itself.

But sometimes it’s not just about pleasure; it’s part of some ‘deferred pleasure’ or idea of self-control that’s inevitably tied to respectability.  (There’s loads of work on class and drinking apart from my ownEmily Nicholls is particularly on how this intersects with gender.)  Drinking less to protect one’s health is a moral action in the sense that it says something about the moral schema you use to weigh up different pleasures.  For a range of reasons, at the moment I’m not in a place to feel I want to drink less.

So I’m not doing Dry January.  Conflict of interest declaration over.

If you want a clear summary of the issues with Dry January, Ian’s piece on the BMJ website is good, and I don’t want to re-hash that here.  The main weakness is that, even excluding dependent drinkers, the evidence suggests that the people who would benefit most from modifying their drinking are exactly the people least likely to start (and finish) Dry January.  Of course, like attempts at recovery, this doesn’t mean the effort was worthless.  Several unsuccessful attempts may have a cumulative impact and lead to success in the end, but it’s still not exactly a ringing endorsement, given that we’re not talking about anything approaching ‘addiction’.

And I always feel a bit sorry for the people I bump into who discuss doing Dry January and reveal they were only drinking about 10 units a week to start with.  The benefits won’t be significant, and the risks weren’t that high to start with – in fact you could argue they’re forgoing pleasure for no clear reason.  But then we’re back to the performance of respectability and the fact that some people get a positive feeling from self-denial.  (The Daily Mash is particularly good on this.)

But going back to Ian’s analysis, there’s just one point I’d take issue with, or modify slightly.  Resources aren’t particularly being found for Dry January, as far as I know.  The beauty of it (and actually the danger) is that it doesn’t require any resource or major policy change.

Locally, we’re just using social media to encourage people to consider taking a break from alcohol, and signposting them to the behaviour change support we already have in place.  Ideally it might lead to more people accessing that support, but that’s not exactly us putting additional resources towards Dry January.

The great value of the campaign, as I’ve said before, is that even for those of us not doing Dry January, it prompts us to consider whether we might want to review our own relationship with alcohol.  Perhaps the reason I have alcohol-free days and keep alcohol-free beer in the house has something to do with Dry January?  (Though personally I doubt it as I’ve been trying to keep 2 days a week alcohol free for well over 10 years now – since I started working on these issues and reading the health and policy guidance.)

This is why I’m so positive about the name and strategy of Alcohol Change UK.  I’m totally on-board with any organisation that aims to get people to reflect on their choices.

And, as I say, this is the beauty of the campaign: it’s not requiring anything of producers, retailers, regulators or drinkers.  It just prompts drinkers to think and maybe modify their own drinking.

But this is also why it’s so problematic for me.  We know that behaviour change isn’t simply about education and people making free choices.  Choices are never made in a vacuum; there’s social and economic context which makes some choices more likely based on the time and place you find yourself in – both on specific occasions and throughout your life.  The more we present drinking and the associated health and social issues as being the result of choices made by the drinker, the less appetite there will be for other approaches, based on price and availability and so forth.  I’m not saying more restrictive licensing, or minimum unit pricing should be introduced, but, as I’ve written before, it’s important that all potential approaches are considered and fully assessed.

So I’m not doing Dry January, but I can see that many people report positive effects.  If you feel you could be persuaded, read this excellent, insightful piece by CJ Flood.

My only question is whether all this attention on individual choices in early January is actually useful in reducing alcohol-related harm at a population level. As Ian suggests, the jury’s still out on that one.

Saturday, 24 November 2018

The iron law of prohibition

I recently wrote about Johann Hari’s book Chasing the Scream.  It’s an unusual thing for me to do to focus so much on another person’s work, and because I enjoyed reading it and felt it had lots of important insights and stories, I felt bad criticising it.  But I’m about to write about it again.

When I was reading the book, I folded down pages or underlined sections that I thought were either interesting or misguided.  Somehow, in my initial post, I missed one key point, which I think is a slightly misleading claim about the potential of legalisation of substances.  I’m going to analyse that, but then argue that nevertheless legalisation may be the right policy.

So, what did I disagree with?  Well, it’s not really Hari’s point; it’s a commonly made claim about how prohibition increases the strength of the drugs.  Hari refers to it as the ‘iron law’ of prohibition.  The point is that if you’re having to smuggle things, then you want the most efficient way of doing it – which in the case of alcohol means spirits rather than beer: a truckload of whisky will satisfy more people than a truckload of beer.  The same could be said of fentanyl today: it’s so potent that it’s much easier to transport than heroin.

This argument is often trotted out by people who want to legalise cannabis, noting that today’s cannabis (often questionably referred to as ‘skunk’) is stronger than what used to be available 20 or more years ago.

And yet whisky wasn’t created by prohibition, and hasn’t become obsolescent in societies where alcohol is legal.  Moreover, people didn’t just drink these things neat; there was a growth in cocktail recipes as people sought to mask the taste.  The transport was separate from the consumption.

And the ‘gin craze’, however accurate as a description of drinking in 18th century Britain, wasn’t driven by prohibition by availability and affordability.  Hari would also say it was driven by the misery and dislocation of rapid urbanisation.  As I wrote previously, we don’t need to – in fact we shouldn’t – look for a single universal cause of substance use issues.  There isn’t one.

In my original piece, I questioned Hari’s claim that ‘relatively few of us want to get totally shit-faced’ (p.230), given the phenomenon of ‘determined drunkenness’.  Here, I want to stress that associating the level of ‘problem’ with the ‘strength’ of a drug is misguided.  Does whisky lead to more problems than beer?  It’s hard to say.  Certainly not everyone who drinks whisky gets drunk, and it’s perfectly possible to get ‘shit-faced’ drinking only beer – I’m living proof.

And if you’re looking for an efficient way to get ‘shit-faced’, it’s not necessarily the ‘strongest’ drink that you choose, but often the cheapest – like white cider, which is a creation not of prohibition, but our slightly arcane tax system.

A clearer ‘iron law’ of prohibition for me wouldn’t be that it creates the strongest or most dangerous drugs (tobacco and alcohol companies are perfectly competent at that); it’s that the strength and general composition of the drugs is uncertain.

I’m not saying that prohibition doesn’t sometimes increase the strength of drugs, or at least limit our choices, but it’s not an absolute ‘law’ – whereas lack of information (which is a key cause of overdose) is.

Also, strength is not the only determinant of problems.  If we’re talking drunkenness we can’t only blame spirits.  And if we’re talking violence, beer is again often to blame.  And we could probably blame wine for a good number of ‘alcohol-related’ illnesses where there has perhaps been very little violence or drunkenness, but the health harms of alcohol have come home to roost.

And this gets us to something of a choice about prohibition or legalisation.  I don’t want to get into the detail of the debate, partly because a lot of it is supposition, and depends so much on what regime is introduced to regulate substances, what the prior culture of the area is, and so on.  Not all countries that allow alcohol have the same levels of alcohol-related harm – even if they have the same pricing and availability.

As always, I could focus not so much on how legalisation would reduce harm for consumers, but for how it would be game-changing for people involved in the production and distribution of drugs, where violence is endemic and whole states have lost their monopoly on the legitimate use of force.

And looking at the consumer side of things too, taking the example of alcohol, we can suggest that there might be higher rates of drug-related illnesses in the long term for consumers, but there would be less crime and violence.  Alcohol-related crime is generally because people are drunk, but most drugs don’t tend to encourage this – or there’s no reason they should.  The crime on the consumer side for these substances tends to be acquisitive to fund drug use, but this doesn’t happen so much in relation to alcohol (particularly not any more) now alcohol is, in relative terms, so cheap.

As others have outlined, in order to ensure there is no black market, the legal price for drugs needs to be relatively low, and of course a potential consequence of that is use increasing, along with associated harm.  That’s what we can see with the growth in alcohol consumption in the UK from the 1960s to 2004.  Various factors combined to make alcohol consumption increase as it became more acceptable, more affordable, and more available.

So is the price worth paying?  Well, for me, as I’ve said, the benefits for producer countries and those involved in the drug trade are clear.  But for consumers and those around them it’s potentially more of a mixed bag.  But I’m still prepared to say it’s worth it – just not because of the ‘iron law’.

Again, without going into the detail (other people can do that better than me), I see this as a question of whether we would prefer the situation today where for consumers and producers life is (to quote another political theorist) nasty, brutish and short, to the situation under legalisation where we’d probably see some higher rates of chronic conditions such as cancer (which we’ve seen with increased alcohol use).  I’d prefer the latter.

That life is nasty, brutish and short for some people isn’t the result of particular substances, even when they’ve been strengthened and adulterated by prohibition.  The nastiness is the result of the wider structures, which can be changed.

Friday, 23 November 2018

In praise of fellowship

Last night I went to my first ever Alcoholics Anonymous (AA) meeting.  It was an open meeting, specially put on for Alcohol Awareness Week.  I’ve been meaning to go to an open meeting for years, and there are opportunities every month, but (like so many things) it’s only getting a date in the diary that made me do it.  I was encouraged that a number of other professionals were there too, representing local support and care organisations from midwifery to probation.

I found the meeting genuinely moving – but of course I would.  Who wouldn’t, hearing stories being shared not only from two regular meeting attendees, but also someone who attends Al-Anon – the sister organisation of AA that supports people whose loved ones have issues with alcohol.  The moving thing wasn’t simply those testimonies, but something about bringing home the human side of my job.  I don’t mean this in the way we often do: slightly patronising, remembering there are ‘service users’ not just numbers in spreadsheets.  I mean something about real human connection.  One person who is alive speaking to another.  I know this sounds both cryptic and trite, so I’ve tried to write something here that explains what I mean.

Sitting in the room, I felt like I was somehow back in the past.

Writing that on its own makes me feel like I’m perpetuating a stereotype of AA, of people sitting in a cold, damp church hall, wearing unfashionable clothes, drinking flavourless coffee.  My experience was far from that.  The coffee was decent, the room was warm, modern and comfortable – and I’m certainly in no position to comment on anyone’s dress sense.

What I mean is that the kindness, community and somehow ordinariness reminded me of the stability and community of my childhood.  I felt like a weight had been lifted.

I tried to explain this afterwards to someone else there, but failed.  I said that sitting there, listening to people’s stories, made me think (as I have about social work in the past) that, done well, this kind of fellowship and community and the genuinely mutual aid it offers would be of benefit to most people.

Of course, the person I was speaking to reasonably and carefully explained two things.  First, that these groups were open to and designed for people who had issues with alcohol.  Second, that these ‘issues’ were of a particular kind – as a doctor quoted in the ‘Big Book’ that I picked up there stated: ‘the action of alcohol on these chronic alcoholics is a manifestation of an allergy; that the phenomenon of craving is limited to this class … These allergic types can never safely use alcohol in any format at all’ (p.xxviii).

I hope I’ve always been respectful to this point of view.  To praise the general principle of mutual aid isn’t to deny the special nature of ‘alcoholism’.

But here’s where I may have been slightly less respectful.  I get caught up in intellectual games and the pleasure of having a neat (ideally slightly unexpected) position when I write about alcohol and other drugs – though I nearly always end up sitting on the fence somehow.

The intellectual game that fascinates me is the classic discussion of structure versus agency, as sociologists would put it.  Or in terms of alcohol problems, does the issue lie in the person or in the bottle – and I like to say that things are complex, nuanced, shades of grey.  (In work, by contrast, I generally tend to want to know ‘the answer’ and get on to ‘do something’.)  This interest in nuance (or fence-sitting) has led me in the past to question whether ‘addiction’ really exists, and to emphasise that if ‘alcoholics’ exist then they are a small sub-section of the group of people who have problems with alcohol, and if we get too caught up in defining ‘addiction’ we’ll fail to pay attention to the whole range of people who are struggling.

So I’ve not really had too much time for this concept of a particular ‘class’ of ‘alcoholics’, as the quote in the ‘Big Book’ puts it.  (Though re-reading some of my old pieces this morning, maybe my love of ‘nuance’ has meant I’m more reasonable than I think.)  There are certainly those who see the use of terminology like ‘alcoholic’ as not only stigmatising but limiting people’s autonomy and potential for recovery.

Having now been to a meeting, though, I feel I’ve been a bit too cold and detached in my assessment.  It’s the same way I feel, on reflection, about the things I’ve written saying that the 2016 Psychoactive Substances Act could, in the long term, be helpful for UK drug policy debates.  The problem with intellectual games, abstract principles and ‘long term’ policy debates is that they’re not human, they don’t feel.  (In the long run, we are all dead.)

The most revealing moment in the meeting was, for me, when various people spoke about ideas of ‘God’ and a ‘higher power’.  This is one of the most debated features of AA, and the one many sceptics leap upon to discredit or disengage with it.

One person explained that, sitting in a church, he wouldn’t feel like he was surrounded by people who understood him, whereas in AA he knew ‘these were my people’.  This is a bit like a phrase I remember Mark Gilman using a few years ago when he came to speak in Dorset, describing an ‘alcoholic’ as someone who has ‘got the spots’ – but it’s also something more.  It’s not just sitting in a room with people who have the same condition or ‘illness’ (many of us have done that at one time or another, and it’s not always useful or fulfilling); it’s about the sense of fellowship.  As someone else explained, for her the ‘higher power’ was something outside of, beyond, herself: the other people in the room.  This is the human, feeling element that I am somehow too easily able to switch off when analysing or writing.

The term ‘alcoholic’ is used in this context without shame or judgement.  It’s seen as a description of a ‘class’ of people, and this ‘class’ isn’t simply defined by alcohol consumed.  It’s a class for whom, as one person put it to me afterwards, just stopping drinking isn’t the solution – in fact, without some wider support, that can often make things worse.

Of course, such people are not the only people who suffer harm from alcohol.  And we need to be flexible in our idea of ‘rock bottom’ (and whether someone actually has to hit it to find recovery).  But it’s hard to sit in that room and feel anything but warmth and admiration for what this fellowship – these people – have done and continue to do.

So going to the meeting helped me remember another way of being in the world.  Somehow more relaxed, more grateful, more structured.  There are various reasons I feel I’ve lost that recently.

But it also made me consider my own drinking.  I’ve not got very far in reading the ‘Big Book’, and so I keep coming back to that section at the beginning by a doctor – William D Silkworth.  There’s a revealing sentence that opens a paragraph describing the nature of ‘the alcoholic’: ‘Men and women drink essentially because they like the effect produced by alcohol’ (p.xxviii).  I certainly do.  I drafted this post last night, and was already envisaging the train back from London on Friday night where I’d enjoy a couple of cans of ‘train beer’.

I’m not suggesting my drinking is ‘alcoholic’, but two things in the past week have made me question my relationship with alcohol.

One was meeting staff and PhD students when I went back to Bournemouth University last Friday to teach a session on ‘controversial cultures’.  Discussing ‘binge’ drinking culture as potentially controversial, I was asked if there was something in the British psyche that means we can’t drink sensibly.  Thinking of James Nicholls, I argued that there isn’t a single, fixed British drinking culture and, anticipating this week’s Alcohol Awareness theme, I emphasised that ‘change’ is possible at a population as well as an individual level.

And the second moment was last night at the AA meeting.  The description of how drinking, for some people, was a way of avoiding the discomfort of living, the anxiety of navigating the world, the awkwardness of being oneself.  (These are all poor phrases to represent what people actually described.  I can’t represent their eloquence in my writing.)

This is why I drink too.  It takes the edge off.

And this, generally, is why people use any drug.  As I remember Wulf Livingston arguing persuasively at NDSAG, much drug use can be seen as functional in some way, even when it’s part of what would generally be labelled ‘misuse’: if the drugs weren’t serving some purpose, people wouldn’t use them.  Perhaps in the long term there’s a better solution, but drugs, too, are a solution of sorts.

Most of us just don’t reach the point described by several people at the meeting, where they were so tired of the repeated pattern of using/drinking that they no longer wanted that life (and therefore no longer wanted a drink because they knew how that ended).  For those of us still drinking, we’ve decided at some level that the benefits still outweigh the costs.

And I don’t just mean a small glass of wine over dinner.  I haven’t tried many drugs, but for the moment I can certainly say that alcohol is ‘my’ drug.  I respect that this isn’t true for everyone (or even most people), but fundamentally I struggle to genuinely understand why people wouldn’t like the feeling of drunkenness.  Why, if there were no commitments tomorrow, wouldn’t people always say yes to another drink?

But sitting in that room, I wondered about that.  Is it a healthy, happy approach to life: when I can, I try not to be fully conscious or present?

Just like my writing, I wonder if my drinking is an attempt to show off, to be special.  Am I trying to be one of Steve Earnshaw’s intellectual, ‘existential alcoholics’?  (Just without the courage of their convictions to be truly destructive.)

And that brings me back to that starting point, which could be seen as simultaneously undermining and celebrating the principles and practices of AA.

(Wait for it, but just so you’re warned, this is the supposedly clever conclusion bit I always aim for when writing a piece like this.  In this case part of me is thinking that it’s particularly clever because I’m being self-referential and self-critical given that I’ve recently been questioning Johann Hari’s claim that the opposite of addiction is connection, and yet here I am praising connection as a solution to addiction.)

The value of AA, to me, is this reminder of the ‘miracle’ of an ‘ordinary’ life, and the benefits of ‘fellowship’.  These are amazingly special things, affirming the value of AA – and yet they are also surely universal (as much as anything can be), which leads me to question how ‘special’ this approach really is.

But although we could all perhaps learn from AA, and despite the fact that this ‘class’ of ‘alcoholics’ aren’t solely defined by their drinking habits, there remains something unique: fortunately most of us are never placed in situations so extreme that we have to think in this way.  And this is perhaps where all of us can take a moment to express what was so fundamental for so many people in the room last night: gratitude.

Tuesday, 20 November 2018

The disease of black and white thinking about addiction

Today (#OurDay) I was at an event in Bournemouth where we were discussing how we could get the different services to work efficiently and effectively together, when there’s decreasing resources at the same time as many of the people who need support are facing increasing challenges, such as unstable housing, complicating health conditions, unemployment, benefits cuts and so on.  As one person described it, it’s a ‘perfect storm’.

This isn’t news, and although the suggestions made by staff were excellent, I want to focus on some conversations I had outside the main discussions – over lunch.

The first thing to note is that despite the astonishing passion and dedication of these staff, who are quite simply not paid enough, the environment they are working in is taking its toll: those decreasing funds and increasing challenges mean people are struggling to see that they’re genuinely making a difference.  Is it just pushing water uphill?  At one point do you decide to stop propping up a system you don’t believe in?

And that brings me onto a bigger point about beliefs that I want to focus on here.

I was surprised that there was still considerable passion not just in the delivery of treatment, but in the recovery / harm reduction debate.  I had naively thought we’d buried the hatchet, but it’s very much alive in terms of how people see the decisions that different organisations and clinicians make.  In a sense, that’s not surprising, though, and it’s partly the fault of commissioners (and politicians) for doing one of two things.

First (and this is my own typical failing) we’ve sometimes been guilty of ducking the issue, of imagining that just saying things like ‘evidence based’ or ‘Orange Book’ will dissolve any conflict.  It won’t.  We should be savvy enough to know that there’s plenty of wiggle room in NICE and PHE guidelines, and there’s always that black box of ‘clinical judgement’.

Second, and conversely, we’ve sometimes been too definite.  Sometimes issues have been presented as ‘black and white’, with a proposal being ‘right’ and all other options ‘wrong’.  No wonder, then, that as the goalposts seem to be moved staff feel betrayed or lied to: if the previous policy was ‘right’, surely this one is ‘wrong – or vice versa.

We should all be a little more cautious when ‘selling’ policies, and open and honest about our motivations and the limits of our knowledge.  (We should also obviously be careful not to introduce any genuinely ‘wrong’ policies in the first place.)

The problem is that when someone is presenting something as a black and white issue, and you’re not sure you agree with their position, it’s easy to get caught in that same binary way of thinking – when what I’d prefer with most of this is to suggest that there isn’t a single right approach, and if we want to talk about services that are tailored to the client, we need to genuinely listen to them.  A one-size fits all approach, whether from a self-proclaimed ‘recovery’ or ‘harm reduction’ perspective is likely to be unhelpful for a number of people.

If this all sounds a bit cryptic, that’s fine.  My real point is something almost trivial about the theory of addiction.  (Which of course is never cryptic.)

In my experience of discussions about ‘addiction’, certain high-minded academics critique the ‘disease model’ of addiction, and possibly even the whole concept.  Then they are advised that the disease model, as championed by NIDA, is valuable because it helps stop addiction being stigmatised.  If people are ‘ill’ rather than ‘bad’, then surely there’s no reason to marginalise them and not offer reasonable healthcare and support?

It always feels to me that critiques of the disease model are therefore labelled as abstract, idealistic, and not in touch with ‘real’ politics or treatment.  This is brought home even more by the close links between the disease model and the ideas of fellowships like Alcoholics Anonymous.

Of course this is naïve on two counts.

First, academics can also have lived experience.  Marc Lewis, who co-wrote one of the pieces linked to above, makes no secret of his.  Indeed, it’s his experience that led him to a different perspective on the issue.  And more broadly, these aren’t simply abstract, academic debates; they can shape policy and treatment.

Second, the idea that being ‘ill’ isn’t stigmatising is absurd.  Any number of diseases and illnesses have been considered moral failings, or simply dangerous and therefore stigmatising, from leprosy to cerebral palsy, to HIV to name just a few.  We don’t manage to treat everyone who is ill with dignity.

Is the disease contagious?  Is it somehow caused by someone’s ‘lifestyle’ (or that of their parents)?  These are key questions not just for the stigma surrounding addiction, but many other illnesses.  And they’re not easy to answer.  (If recovery is contagious, then isn’t addiction?)

But it seems to me that this remains the frame of the debate: brain disease a realistic, pragmatic, stigma-reducing idea; critiques perhaps well-intentioned, but abstract and academic.  Criticising the disease model is seen as a hobby of abstract academic thinkers not grounded in the real world.  (Maybe that’s me being oversensitive, but stick with me.)

That’s why I was surprised to hear critics of ‘harm reduction’ (self-confessed advocates of ‘recovery’) also criticising the disease model.  But of course this made perfect sense.  For them, the reliance on methadone (and an emphasis on ‘optimal dose’ in the Orange Book that is relatively high compared to much practice) represented a medicalising of addiction based on a disease model.  If you diagnose a disease, our standard medical approach is to prescribe, well, a medicine – in this case methadone.  But methadone is nothing like an antibiotic, or steroid.  It doesn’t in itself fight an infection or reduce swelling; it feeds a physiological dependency.

I don’t really want to get drawn into the details of this debate.  It would take too long and the evidence isn’t always perfectly clear.  It would also mean conducting a debate in ‘bright lines’ when the reality is a little more muddy.

I just want to pause on this point: recovery advocates can also be critics of the disease model.  This is of course completely coherent, and maybe it’s only me who’s intrigued, but it highlights that these debates aren’t simply black and white.  If we had to choose a ‘side’ between ‘harm reduction’ or ‘recovery’ we might find ourselves alongside with some people we don’t agree with regarding the very nature of ‘addiction’.

An overly prescriptive idea of ‘right’ and ‘wrong’ approaches to treatment actually contains the seeds of its own downfall.  If your enemy’s enemy is your friend, you’ll find that, actually, we’re all friends.  We shouldn’t be choosing sides.  Not when there’s bigger battles to fight – like that perfect storm.

Monday, 19 November 2018

Alcohol Change: The Voice of Moderation?

Today the new charity formed out of the merger of Alcohol Concern and Alcohol Research UK has been launched.  You might remember that when this merger was first announced I was pretty sceptical that it could work.

I felt that fundamentally the two organisations had different visions that were basically at odds with each other.  Alcohol Research UK sought to improve knowledge and information to help reduce alcohol-related harm, while Alcohol Concern sought to eliminate alcohol-related harm altogether.

These might only be seen as matters of degree, but the idea of a world free from alcohol harm is as utopian as the UN’s claim that we should create a ‘drug free world’.  Given what we know about alcohol, the only way to guarantee you won’t suffer any harm related to it is not only for you not to drink, but for no-one around you to drink.  A world free from alcohol harm means, in reality, a world free from alcohol.

The new organisation – Alcohol Change – defines its vision as being a society where there is an end to ‘serious alcohol harm’, and envisages bringing this about by improving knowledge, policy and treatment, and therefore changing cultural norms and drinking behaviours.

You can read about Alcohol Change’s proposed approach in a kind of ‘state of the nation’ report released to coincide with Alcohol Awareness Week.  I just want to pick out a few gems and talking points from this that have made me eat humble pie: I think that maybe the staff and Trustees at Alcohol Change have managed to do what I thought was if not impossible then certainly highly challenging.

First, there’s a paragraph in Alan Maryon-Davis’ introduction that I think should be shared with every journalist and political commentator ever considering discussing alcohol policy:
There is nothing inevitable about the way we drink, how we behave when drinking or how difficult it is to access the support that can help turn lives around. Research shows that the majority of dependent drinkers recover, that heavy drinkers can make new choices, and that the social and cultural environment in which people drink can and does change. Change is possible for individuals, and it is possible for society. (p.1)
Far too often we view drinking habits as unchanging and unchangeable: we’ve been drinking too much as a nation since well before William the Conqueror arrived.
‘Drinking in particular was a universal practice in which occupation they passed entire nights as well as days. They consumed their whole sustenance in mean and despicable houses, unlike the Normans and French, who in noble and splendid mansions lived in frugality … They were accustomed to eat till they became surfeited and to drink till they were sick. The latter qualities they imparted to their conquerors.’ William of Malmesbury, 12th century

But that raises the inevitable question: if change happens, and we can shape it, what sort of culture should we be aiming for?  And this is where the ideas of knowledge, information and choice come through strongly and, for me, positively in the Alcohol Change document.

I’m generally sceptical about health and behaviour change programmes based around ‘choice’ because they tend to ignore (or at least downplay) the level to which people’s choices are structured by the situation they find themselves in: who their parents are; where they live; how much money they have; the job they have; the personal relationships surrounding them; and so on.

But this document doesn’t duck this issue; it notes the importance of culture and norms in shaping our preferences and expectations, and how these in turn can be shaped by policy levers.

The changes in alcohol consumption shown in the graph above were partly down to some short and medium terms factors – both conscious policy decisions and the simple fact of a dire economic situation – but they cast a very long shadow, with alcohol consumption for most the twentieth century remaining at historically low levels.

And the policy point is made with a bit of nuance too.  As I’ve argued elsewhere, too often policy discussions focus on exciting new initiatives – such as minimum unit pricing – at the national or even international level.  In reality, there’s massive variety and impact generated by local decision-making – but somehow Town Halls are seen as less interesting than Whitehall.  It’s refreshing, therefore, to read a strategic document that emphasises the importance of engaging with ‘local government … commissioners of treatment services [that’s me!], the police, local planning, and all the other local stakeholders with a role in reducing alcohol harms’ (p.11).

For me, this document seems to have got the approach just right.

There will of course be campaigners who feel that ‘serious’ is a weasel word that dilutes the utopian aspiration of a world completely free from alcohol harm, and the focus on knowledge and information is a naïve concession to the evil industry of ‘big alcohol’.  And conversely there will be libertarians who see the emphasis on culture change as beyond the scope of reasonable activities, which should allow people to pursue their own choices.

For me, that’s the ideal position for a new charity like this to be in.  I’ve complained before about the polarised, adversarial approach that often characterises alcohol policy debates – ‘public health’ versus ‘the industry’ – where both sides have some valid points but neither is listening to the other.

There will always be these voices at either end of the spectrum, and there’s little value in duplicating one or the other – a simple approach to balance will mean both are heard (or at least given the opportunity to shout over each other).

The value of Alcohol Change should rest in being a different voice, not associated with a partisan position but as a trusted messenger and ‘truth teller’.  And in playing that role – rather than simply being a vocal, idealistic (even utopian) campaigning organisation – it may find its ideas and proposals are listened to more seriously than either of the two extremes.  As so many alcohol researchers and lobbyists have noted, there is great power in being able to define what the ‘moderation’ is.  Alcohol Change can position itself as the voice of moderation in more ways than one.

The last time I wrote about this merger, I summed up my scepticism with a reflection on my personal feelings – valuable because so often (as drinkers, professionals or campaigners) our views on alcohol are shaped by personal experiences and beliefs.  I said that while I would be keen to work for Alcohol Research UK, I just couldn’t see myself being a good fit with Alcohol Concern, given its hardline, lobbying approach.  I don’t know whether it’s praise or not, but I can honestly say that Alcohol Change looks like the sort of organisation I’d enjoy working for.