Monday, 29 October 2018

Are compassion and connection the answer to drug policy debates?

Two people I have a huge amount of respect for – Suzi Gage and Harry Sumnall – have just published a paper encouraging us all to have a bit more restraint when discussing the implications of the Rat Park experiment.  Just like the original author, Bruce Alexander, did, in actual fact.

I was familiar with the experiment somewhere back in the mists of time, but (setting aside Bruce Alexander’s appearance at the 2016 New Directions in the Study of Alcohol conference) the reason it’s on my radar now is that Johann Hari and others have used it to campaign for the legalisation and regulation of drugs.

For those of you who are interested in finding out more about the experiment, I’d recommend Suzi and Harry’s article.  Basically, the study is typically seen as showing that a rat’s propensity to get ‘addicted’ to a drug (morphine in the case of Bruce Alexander’s work, but others have used cocaine) is not simply dependent on the drug, but their environment.  Put rats in bare, individual cages and they’ll use intoxicating drugs to the point of incapacitation or even death; put them together in a ‘Rat Park’ with other rats and entertainment and they’ll pretty much ignore the drugs.

The problem is, of course, that it’s more complicated than that, and in any case it’s hard to extrapolate from a small animal study to a global policy for humans.  It’s often overplayed because it’s an eye-catching story.  In itself, the research isn’t miles from the general consensus about what causes issues like addiction: a mixture of the substance, the person and wider circumstances.  The ‘biopsychosocial’ model, if you like.

The point of all this discussion is that reading the article reminded me I had recently made the effort to read Johann Hari’s Chasing the Scream in full.  I felt guilty at criticising him on the basis of TED talks or newspaper articles without actually having read the whole book.

I’m not particularly negative about the book.  It’s well written and the interviews and storytelling are engaging.  I also want to believe the conclusions, and I like the way he writes about how he reached them, and the uncertainty about whether they hang together.  I largely agree with the conclusions.  I think the world would be a safer place if more drugs were regulated and available through legal routes, whether prescribed or sold.

Unfortunately, Hari was right to be concerned: the conclusions don’t actually hang together.  I know the book isn’t new, and other people have analysed it before me, but I it’s been a useful exercise for me to think all this through, and it’s important for our debates about drug policy.  It can feel like we’re at a fork in the road at the moment, not just seeing possibilities for change, but real change itself.  Cannabis is legal for recreational use in countries around the world, and more and more places are operating decriminalisation, either in theory or practice.  The arguments and claims we make for these policies, are important.

So just noting a few of the issues with Johann Hari’s claims, he can’t seem to decide whether drug use is exciting or boring – and he sees this as crucial to the solution.  So he quotes John Marks, who prescribed injectable heroin on the Wirral in the 1980s, as saying: ‘I try to make my clients realise that what they’re doing is boring, boring, boring.’  Except that’s not (always) the case.  And it’s not what Hari says elsewhere in the book.  Using heroin can be exciting – and not just in terms of the chemical ‘high’.  As Steve Wakeman has powerfully described, the routine of getting together enough money, making the deal and using the drugs provides a focus and some excitement to the day, and also offers people a sense of expertise and achievement.  It can also provide a community.

As I say, Johann Hari knows this.  When he quotes John Marks on p.211, he has already quoted Bruce Alexander on p.176 saying that when the life of a heroin user is compared with what might happen if they got a ‘McJob’ or became a janitor, it seems ‘really exciting’.  Hari doesn’t have to agree with everyone he quotes, but he does need to balance different perspectives up against each other.

Of course it’s possible that, following the idea that people ‘grow out’ of most patterns of substance use, heroin use is exciting to start with, and maybe for many years, but at a certain point there comes a time when it seems ‘boring, boring, boring’.  But as the Bruce Alexander point shows, this depends on what else is on offer.  It also means that one approach won’t make sense for everyone.

This has important consequences for policy.  Heroin assisted treatment (HAT) is more likely to work if the alternative isn’t seen as exciting – because HAT will never be exciting in that way, as Steve Wakeman has again described so well.

So we’re not clear from this book what treatment we should be offering people, but perhaps that isn’t much of a criticism.  This is really a book about the global ‘war on drugs’.  So let’s think about drug policy more broadly.  Hari suggests that use of substances isn’t down to access, but in fact there’s plenty of evidence that use of alcohol (and in fact other drugs) goes up and down depending on how accessible it is.  Some might argue that overall levels of substance use stay the same, people just switch from one substance to another (even across legal boundaries).  However, we know that overall substance use varies over time, and this is partly about access and affordability.  In many countries, the interwar years saw slumps in alcohol use not because everyone was switching to other drugs, but because money was tight and it was harder to get hold of a drink because of stricter controls or even prohibition.

But citing Bruce Alexander again, Hari states: ‘The answer doesn’t lie in access.  It lies in agony.  Outbreaks of addiction have always taken place … when there was a sudden rise in isolation and distress – from the gin-soaked slums of London in the eighteenth century to the terrified troops in Vietnam’ (p.228).

There are two problems with this approach.

First, it’s not clear that high levels of substance use are associated with agony so much as affluence.  Perhaps affluence comes at times of change and upheaval, but the relationship is more complicated than that.  Of course, ‘addiction’ is a problematic concept, and it might be that if we define it tightly enough then we can see that instances increase at times of ‘agony’.  There’s certainly no doubt that difficult experiences can drive people to substance use.  But dealing only with ‘agony’ – or even seeking the prevention of ‘agony’ would leave us with a pretty narrow, ineffective drugs policy.  Too often, the book slides into describing drug use as inherently problematic (e.g. pp.241-2) – and then moments later talking about the inevitable human desire for intoxication.

Second, availability is a key factor that is part of the mix.  The ‘gin crisis’ (or rather the perception of a crisis) occurs not simply because of an increase in agony, but also because of availability of a particular product, which has been developed through technological innovations and the confluence of foreign policy (gin as a patriotic Protestant alternative to French brandy).  Use of heroin amongst American troops in Vietnam was partly the result of it being available.  Why not other substances?

The response to this is that the substance is secondary: whatever is affordable and available will be used to soothe the pain.  But was there less pain in the ‘dark ages’?  During the English Civil War?  During the World Wars of the twentieth century?  We’re drinking more now.  If drinking follows pain, that simply wouldn’t be true.

And, crucially, we do drink despite it being legal.  Campaigners might see legalisation as ‘a drama reduction programme’ (p.263), but the most important bit of drama relates to the murderous crime drama that is the production and distribution of drugs.  There’s plenty of drama in consumption even when substances are legal.  If the ‘fun’ were taken out of drug use, wouldn’t people move onto something else (like the ‘carnival of crime’) to get it?

These might seem like flippant points, but they have important implications for policy.  ‘Addiction’ is not the only problem related to substance use, and it doesn’t only relate to ‘agony’, though this can be an important factor.

To challenge this ‘agony’, Hari’s rallying cry is that the opposite of addiction isn’t sobriety, but ‘connection’ (p.293).  ‘A compassionate approach leads to less addiction’ (p.252).  His hope is that people and politicians of all stripes will begin to see that drug policy ‘isn’t a debate about values’ but rather a debate about harm.  ‘We all want to protect children from drugs’ (p.252), for example; we just disagree about how best to do this.  I’ve written before about how ‘harm’ is extremely hard to define.  In fact, it’s a weasel word that makes us think we agree when we don’t.

I don’t want to downplay the importance of Hari’s claims with these criticisms.  When he describes the issues surrounding the criminalisation of drugs and the broader social and economic deprivation that often goes with them (p.238), we could be talking about many areas of the UK today: if we take away the drugs, what is a person potentially left with?  No job, or realistic prospect of getting one.  No stable, safe, warm and dry accommodation.  No supportive personal relationships.  Of course this is a particularly negative view, and everyone carries assets with (and within) them, but the reality is that ‘recovery capital’, just like all other forms of capital, is not evenly distributed across society.

But the general point regarding legalisation is that it would reduce stigma.  Hari quotes Joao Figueira who suggests that people who’ve got into problems with alcohol were always treated as ‘friends’ and given support, and now the same humanity and sympathy are offered to people who use illicit drugs (p.250).  But I don’t recognise that in our approach to people in the UK today.  Public debate, and even plenty of private interactions, often don’t show humanity and compassion to people who run into issues with any substance, including alcohol.  (If you doubt my position, take a look at the articles and comments on the Dorset Echo website from time to time.)

Legalisation is not an easy answer to reducing stigma.  In fact, as substances become more available, and more people use them without problems, the potential judgement might become more harsh.  At the moment, many people have misconceptions that illegal drugs are immediately addictive.  If they were disabused of this notion by seeing plenty of people using them recreationally, perhaps they would identify the problem as residing not in the substance but the individual.

I agree that compassion could reduce problems surrounding drugs, or at least help us deal more effectively with them.  The issue is that compassion, and the approach Hari sees as compassionate, need some serious work to make them politically acceptable.

Understandably, Hari seems to be writing for the people who are going to read his book: bluntly, middle-class, liberal, intellectuals.  When he claims that we all want to reduce harm, I don’t recognise that in our political culture today.  There are plenty of people who see punishment not as a form of rehabilitation that may be more or less effective, but as something that has a moral purpose of its own.  When Hari suggests that ‘most of us don’t object to drug use in and of itself.  We worry about the harms caused by drug use’ (p.266), I think he underestimates the public opinion challenge surrounding legalisation.  Even drinking to intoxication is condemned in our society, and that’s making use of a legal drug.  Use of illicit intoxicants is far from acceptable.

I know this is changing, and there are organisations like VolteFace who are making waves in changing the terms of debate, but this is hard work that needs to be done carefully, and it can’t be done simply by calling for compassion or believing that intoxication is acceptable.

Reading the book reminded me of why I find this kind of line on drugs policy disappointing: it’s looking for a magic solution to a multifaceted issue (or, more accurately, a whole range of issues) and overplaying its hand.  That’s why the article by Suzi and Harry reminded me of my thoughts on the book, which I’ve meaning to write down for a while: we need to be really careful about what we’re promising, and the problems we’re trying to solve, otherwise we could end up in a worse position than we’re starting from.

Tuesday, 11 September 2018

Let's have an end to tall tales about addiction

I’ve talked about addiction on this blog before.  I’m not being flippant, given basically the whole thing is about alcohol and other drugs.  I mean I’ve written about the nature of addiction, and whether it’s useful as a term.

I think I’ve always been honest that I’m not an expert on this.  I’m not a clinician or a technical researcher.  I’m a council worker who’s done a bit of academic work – in sociology!  I’m not entirely sure why, but I’ve started thinking about this again.  Well, I know why – I’ve been passed some fascinating reading – but I’m not sure what started this or why I’ve found it particularly engaging.

Anyway, onto the meat of the thing.  I’ve written before about how we’re generally attracted to black and white, binary thinking.  In addiction debates, this often plays out as a choice as to whether ‘the problem’ lies in the person or the substance.  For example, is it that certain people are unable to drink alcohol in a controlled fashion (‘I am an alcoholic’ – but other people aren’t) or that there is something inherently problematic about the substance itself (we should control or even ban alcohol because it is ‘no ordinary commodity’)?

Of course I’m bound to say, being the person I am, that ‘it’s a bit of both’, but often that nuance means sacrificing clarity, and the action that tends to go along with it.  As academics (and in fact civil servants) are told so often: it’s hard to prompt the implementation of an initiative if you don’t have a clear ‘narrative’ to explain it.  I’m not sure we have a clear narrative on substances and addiction.  Or maybe we do, but it’s not stable: it’s clear for a few years, then it changes.

Because then along came Johann Hari, re-popularising Bruce Alexander’s Rat Park, explaining that the key to understanding addiction is social connection: if you put rats not in bare cages, but an open ‘park’ with company and plenty of fun activities, they don’t want to use morphine/cocaine.

So we have a third explanation: addiction is about social context.

That’s not a new insight; Rat Park isn’t a new experiment.  But what is new (to me, though still predating Johann Hari’s interest) is an article by Gene Heyman (shared with me by Gary Wallace, a wonderful commissioner doing wonderful things in Plymouth).  Heyman looks at big datasets from the USA to assess hypotheses like whether addiction is related to the substance, the individual, their social context (e.g. education) etc.

It felt particularly timely reading this as issues around decriminalisation, regulation etc seem to be more on the political agenda than they have been for years, and the sector (in the UK) is increasingly operating under a new organising framework: no longer crime or employment, but ‘adverse childhood experiences’.  That is, substance use is often a response to trauma.

I have a lot of time for this explanation (for a more academic exploration, see Hanna Pickard’s work).  However, not every heroin user is a victim of abuse, or a survivor or trauma, and this must be more widespread than we care to admit if we were to include all dependent drinkers in this category.

Of course, that raises two questions: first, is dependence the same as a ‘substance use disorder’ or ‘addiction’; and second, what does this mean for the claim that addiction is an ‘equal opportunities’ disorder?

I would respond by saying that this is political, and Gene Hyeman can help us with this.  It’s political because the choice of what narrative or ‘story’ to tell about addiction affects the policy solutions we come up with (and how likely these are to be implemented).  (Think Kettil Bruun choosing to emphasise the population-level issues associated with alcohol, partly in order to avoid stigmatising ‘alcoholics’.)  Gene Heyman helps because his way of conceptualising the issue cuts through some of this.

Heyman notes that we have a definition issue: what is addiction, and how does it relate to dependency?  He notes that discussions often become circular: if you don’t behave in a certain way (including relapsing or needing treatment) then you weren’t ‘really addicted’ in the first place.

But he points out that so long as we’re reasonably consistent in how we apply it, DSM (IV) definitions are pretty reliable.  These count symptoms, and if you have enough then you count as having a substance use disorder (dependent on terminology at the time).  (I’m going to ask properly knowledgeable professionals to cut me some slack here.  I’m no expert, as I’ve said, but I’m also trying to make this simple and straightforward.)

We need to be careful whether we’re seeing recovery as meaning you’ve still got ‘symptoms’, but below the threshold number, or in fact you’re now not using at all (you’ve got no symptoms).  But there are ways of controlling for this, and basically, once we get beyond this, we can see something of a standard distribution of misuse, just with varying levels of duration.  (You’ll need to read the whole article if you want a proper, reasoned explanation of this conclusion.)

And we need to remember that the people we see in treatment are a small section of those who use substances, and even of those who run into issues with substances.  I’m perfectly happy with that.  In treatment discourses, we often talk about ‘recovery capital’, meaning the stock of factors that support people to improve their situation.

Generally, people have a much better chance of recovery: if they have some kind of financial safety net and stable accommodation (physical capital); if their wider health is pretty good and they have some life and employment skills they can draw on (human capital); if they have a particular set of values that fit with the life they’re trying to form (cultural capital); and if they’re surrounded by supportive, like-minded people (social capital).

For lots of people who drink too much, they have a good stock of this recovery capital, and if they can break the habit of drinking heavily then they will quickly improve their health and wider social situation.  For these people, for example, a GP-led detox might be perfectly sufficient for them to maintain their recovery for a long time.

Or think of the memoirs and blogs that seem to have multiplied in recent years, describing how once the author jettisons alcohol they become fitter, happier and more productive.  I know that’s a simplification of the narratives, but it can sometimes feel that there’s assumption that the other elements of someone’s life are ready to fall into place if someone stops drinking, even if this takes some work.

I think it’s important to remember that’s not so easy if there’s no stable accommodation that’s accessible to you, if your personal relationships are destructive, with little chance of escape, there’s no jobs locally and your employment prospects aren’t great because your education and CV don’t look too great to people who are looking at you for the first time.

It’s people facing these more challenging circumstances – with less ‘recovery capital’ – who are most likely (or should be most likely) to benefit from treatment services.  They’re also – for precisely that reason – the people most likely to relapse, and to struggle to recover long term.

I know I’m telling people what they already know.  I know this could be seen as a straw man.  (Even Peter Hitchens, a vocal opponent of intoxication and substance use generally, can’t decide if it’s the substances that are evil, or the people using them who are flawed – he probably thinks it’s a bit of both!)

But first I would recommend that anyone who hasn’t reads through the article.  It has interesting points to make about inequalities, prohibition, and what treatment can and should offer.

Second, I want to ask (or just wonder aloud) whether it’s possible to break away from the soundbite approach of ‘addiction is about social connection’ or ‘addiction is a response to trauma’ or ‘addiction is based on genetic predispositions’ or ‘addiction is the result of using an addictive substance’.  It’s all and none of these things, for a whole number of people.  How can we talk about ‘tailored treatment’ and ‘trauma-informed care’ if we can’t even see the nuances in the disorder we’re trying to treat?

I know the attraction of a big idea.  I know the attraction of a simple ‘story’.  But attractive as that is, it often leads to the wrong solutions, and all interpretations are time-limited: with falling crime rates, we don’t talk so much about heroin users committing acquisitive crime now; it’s more about breaking the cycle of ‘adverse childhood experiences’.  If the symptoms and ‘disease’ have stayed the same, why should we be changing what we do?  Or do we just say we’re doing different things, and carry on regardless?

Perhaps a more sustainable approach would to be to admit that we’re dealing with a spectrum of issues, with a range of causes and factors.

Providers in the sector are often told to diversify and not be reliant simply on one large contract.  Perhaps commissioners, lobbyists and policymakers could follow the same advice and not be reliant on one big ‘story’?

Monday, 10 September 2018

You can't be an expert on your own

After attending EXCO 2018 a couple of weeks ago, I don’t have the answers to what Excellence in the Commissioning of Opioid Use Disorders looks like.  But then I wouldn’t expect to.  In fact, I think I’m giving the conference the highest praise possible when I say that it got me thinking in depth about commissioning and how we do it. 

Any conference has, almost by definition, some element of ‘broadcasting’; people telling a room what they’ve done, and ideally reflecting on what they’ve learned.  But sometimes the most useful part of a conference is the human contact, the genuine sharing of ideas.  In simple terms, a conversation rather than a lecture.  It’s this that sets a conference apart from reading a book or an article, or even watching a webinar. 

EXCO was no exception.  For me, some of the most interesting and useful moments were in conversations over coffee or lunch. 

And I think this applies more widely: there’s a real need for genuine conversations in commissioning.  I don’t necessarily mean sitting over coffee and chatting things through.  This kind of exchange of ideas could be virtual, through online communities (I’ve just joined an interesting group on Knowledge Hub, generally used by local government staff). 

And in fact it’s not just about actual conversations, whether virtual or ‘IRL’.  I’m thinking more of an exchange of ideas.  It was in some ways a point from Annemarie Ward about our sector being in competition that got me thinking again about how we might approach things differently – and that wasn’t part of a conversation so much as her point percolating through my mind on the (long!) drive home from Manchester. 

But writing about how we need ‘an exchange of ideas’ is exactly the sort of thing that generally winds me up.  It’s no wonder that when commissioners like me use this kind of phrase we get told, quite rightly, ‘you talk, we die’. 

But I think it’s important.  It’s about the way we approach our jobs – and without doing this in the right way, we really are in danger of pointless talk. 

What do I mean by pointless talk?  Well, the kind of ‘broadcasting’ I talked about earlier.  Too often, when a group of professionals come together to share ‘best practice’, it turns into a bragging session.  Too often, when an organisation like Public Health England (PHE) or the Local Government Association (LGA) release a guide to something it’s full of ‘case studies’ that are simply puff pieces – opportunities for people to boast about how wonderful their organisation (and, by implication, their own work) is. 

My fear about an ‘expert’ faculty is precisely that: it will become an opportunity for those involved to broadcast information that confirms their status as ‘experts’.  We don’t need another organisation like that.  Instead, we should be more honest and collaborative.  Perhaps if, instead of talking, we made more of an effort to listen, share and cooperate, then fewer people would die. 

I know this sounds rich coming from someone who actively blogstweets and writes, sharing his own views, but maybe it takes one to know one.  I like a bit of attention, and I find it rewarding to feel like an expert, but on lots of things – actually, everything – the attention shouldn’t be paid to me, and I’m not the ‘expert’ voice you should be listening to. 

But what does this mean in practice?  It means that I think the Faculty could be a great vehicle for these conversations.  But I would suggest we need to approach these conversations differently to lots of interactions I see (and participate in!) at the moment. 

(I appreciate it’s slightly odd that I’m stating a definitive opinion at the same time as I’m denying expertise or that anyone has the answer.  I’m afraid you’ll have to live with that.) 

So let’s turn a management platitude on its head: don’t come to me with solutions, come with problems.  If you come to a group with a problem, there’s instantly a conversation.  If you come with a solution, you’re often just grandstanding. 

You might have thought PHE could play this role as a facilitator of conversations, but it’s clear it’s not quite managing it at the moment.  Having heard Rosanna O’Connor speak at EXCO, I wonder if we – local commissioners – are part of the problem.  (Of course we are.)  She made the point (though not in these words) that the sector can look a bit like it’s crying wolf about funding cuts when all the stats still look rosy, because no-one wants to admit that things aren’t going well in their team, their organisation, their local authority.  And if we don’t want to tell them things aren’t working, how can they host open, honest conversations? 

So I think there is a potential role for a Faculty of Commissioning, but while I’d love to be an expert, a person can’t be one on their own.  Perhaps this faculty could be a place to share mistakes and problems as much as ready-made expertise. 

It’s this slightly pessimistic vision that could make me optimistic.  How about you? 

Saturday, 28 July 2018

Addiction and the common cold

As you could probably tell if you read my last blog post, I’ve been thinking a lot about what the ‘problem’ (or rather what problems) in relation to alcohol it is that policy and treatment are trying to solve, and whose responsibility these might be.  An analogy that’s often bandied about is one of wider health or healthcare – addiction is a health, not a criminal justice, issue – particularly if we note parallels with mental health.

One of the best pieces I’ve read about mental health care was this article by Hannah Jane Parkinson.  It starts by considering the common analogy that we don’t think of people with broken legs the way we do people with mental illness, and if we did there would be less stigma and people would be more likely to receive effective treatment.  But the challenge she puts back is that, in fact, mental illness isn’t much like having a broken leg.  I agree, but, being a bit of a contrarian, I want to suggest the analogy might still be useful – or at least some form of analogy with physical health.

If you look at many physical health conditions, although the pathway won’t be immutable or the same for every patient, you can be given a pretty good idea of what it’s likely to look like, and where the decision points might be along the road.  I’m not sure we’ve always managed that in substance misuse treatment services.

But it’s not just about that kind of learning.  If we think a bit differently, then an analogy like a broken leg or the common cold does actually make a lot of sense – and perhaps even helps illuminate who might be seen as responsible for the various elements of prevention, vaccination, rehabilitation and cure (or however we badge things).

Take the common cold, which is a regular source of frustration to me: why haven’t we found a cure yet?  Why did we stop the trials at l(well, near) Porton Down?  (No, not those trials.)  Well the answer is that what we see and diagnose as the common cold could be seen as a set of symptoms; there are many different viruses that actually cause them.  And even if two people have the same virus, it might affect their bodies in different ways: when I get a cold it always starts with a sore throat; for other people it’s sneezing or a runny nose.

So let’s apply this as an analogy to substance use disorders (SUDs).  Think of that DSM-V definition.  It, just like our understanding of the common cold, is a set of symptoms.  And it’s plausible to see the cause as similar: a range of things lead people to use in these ways, even if they can be grouped together in the same way that cold viruses can be (as adverse childhood experiences, for example).  And what that disorder looks like will be different to different people.  Not everyone has a sore throat when they get a cold, and not every DSM will be ticked for substance use disorders.  And, importantly, not every cold you get has the same symptoms – sometimes there’s no blocked nose, sometimes there is – and so not every episode of substance misuse will look the same even for the same individual.

So that tells us how SUDs look like common colds.  But what can we learn about how we address them?

First off, let’s think about prevention.  We talk about good habits: coughs and sneezes spread diseases, wash your hands, don’t go into work needlessly if you’re ill, get lots of sleep, etc.  There are precautions you can take as an individual to reduce the work to yourselves and others.  The same is true for SUDs.  So local and national government has a role in making sure social structures and opportunities don’t foster illness.

In terms of treatment for a cold, we just relieve the symptoms.  We take medication like Lemsip.  We avoid making it worse, maybe by taking some time off work.

We can do the same for SUDs – though maybe methadone is a more likely medication than Lemsip, and harm reduction interventions include needle exchange rather than honey and lemon.  This is where substance misuse treatment services come in.

But none of that stops me being grumpy about the common cold, and wondering if we couldn’t do more.  Why did we stop those experiments at Porton?  Well, apart from the ethics, from what I can tell it was felt that although the symptoms looked similar, the viruses were too different, and mutating, for us to develop a single treatment or vaccine.

Instead, what looks more promising is accepting there probably won’t be a vaccination, but developing medications that, rather than just easing the symptoms, stop our bodies from providing what the virus needs to replicate.

Interestingly, and encouragingly (or frustratingly, depending on your outlook on life) none of this is alien or new to substance misuse services.  We can try, but we won’t ever completely stop people being exposed to risk factors for substance misuse.  So when they are exposed, we want to make sure they have resilience, and then decent self care if they’re in an episode of misuse.  Then, we can provide medication – Naltrexone, for example – that reduces the chances that someone’s exposure will lead to another episode.

So maybe that analogy with physical illness isn’t terribly useful – but not because it’s not accurate; rather it doesn’t tell us much we don’t know already.  (So this was definitely a worthwhile blog post…)  It perhaps tells us that we sometimes underestimate how complex and inexact medical science is, even for apparently straightforward ‘physical’ illness.

And it’s not just the common cold.  Let’s go back to the broken leg analogy.  That is, effectively, a symptom.

There are lots of potential causes of a broken leg – including skiing and playing rugby – and lots of people will carry on putting themselves at risk after they’ve broken their leg once and it’s healed.  (Perhaps, without being too flippant, being a rugby player is a chronic, relapsing condition that’s harmful to your health and family relationships?)

We can try to reduce people’s exposure to risk, and we can try to reduce their risk by ensuring diet and behaviour gives people relatively strong bones, but people will still break their leg.  And once they have, sometimes it’s easily healed, sometimes not.  Sometimes there are long term consequences (you’re unable to play rugby again); other times life is pretty much back to normal.

The treatment will involve a number of different professionals, even if what is being treated is just the broken leg itself.  (Think of doctors, nurses, drug workers, social workers etc helping with SUDs.)

But if the broken leg is a symptom of something broader, like osteoporosis, and just stopping playing rugby won’t be enough to prevent it happening again, then other specialists might need to get involved – and only then are we talking about something more than symptomatic relief.

Fundamentally, none of this is terribly illuminating, I must admit.  And what I certainly don’t want to do is undermine the crucial point that treating mental health or substance use disorders is like ‘treating’ a broken leg.  They’re not, exactly – though the analogy can actually be comforting: we do what we can.  What this discussion can remind us is that maybe substance misuse isn’t quite the special case we might think it is.  Medicine, even for physical health, isn’t in practice an objective science so much as a personal, human and nuanced practice of care.  Sometimes it’s nice not to be special.