Thursday, 9 June 2016

The good old days of the NTA?

Over the past few months, I’ve been working on two key projects as part of my role at Public Health Dorset.  First, we’ve been developing a joint strategy for alcohol and other drugs that applies across the three upper-tier local authorities of Bournemouth, Poole and Dorset.  Second, we’re starting work reviewing our existing treatment services and thinking about what we might put in place when we need to recommission in the next year or so.

Both of these projects have really brought home to me two points: there’s a huge range of ‘problems’ and ‘solutions’ that can be ascribed to alcohol and other drugs; and without the NTA and centrally-dictated policy, locally areas have a huge amount of autonomy in defining and pursuing these problems or solutions.

Neither of these points will be much of a surprise to regular readers of this blog, as they’re themes I often mention.

Now there are definite positives in this new environment of local autonomy: rural areas without any significant level of crack use don’t have to spend valuable time and energy writing a dedicated crack strategy, for example.  But that process of trying to identify ‘what is the problem’ and ‘what are we going to do about it’ isn’t simple.

We can sometimes think that ‘evidence’ or ‘needs assessment’ are going to provide the answers about what we should do locally, but that’s to overlook the fact that the only reason that was the case under the NTA was that they’d already set not only the terms of the debate, but also the answer.  The debate was set in terms of how we can best reduce crime and blood borne virus transmission, and the answer was methadone maintenance treatment for a sustained period of time (with a bit of emphasis later on completing treatment).

Now, because there are myriad problems that relate to substance use, and no single organisation dictating the answer, neither the aims nor solutions are clear.  And it can be a challenge to bottom out all those discussions.

As I say, there are positives.  It means a genuinely joint approach can be taken to commissioning and policymaking locally, which is what our strategy in Dorset is all about.  And commissioners of substance misuse treatment services are less likely to try to do everything in isolation from other areas (though that’s partly down to financial imperatives).

But going through that process isn’t just challenging; it’s time consuming – which means resource-intensive.  And those discussions then have to take place in all the 150 or so areas that commission services in England, not just in Whitehall.  And those discussions about whether this was an issue worth investing in just weren’t on the agenda at all.

I’m not saying it’s a bad thing one way or the other, and as well as opening the possibility of better local policymaking the change could be said to make policymaking more democratic and accountable to local residents.

But I do want to highlight how complacent it was possible to be, and how easy it was to demonise Paul Hayes for making a bargain with the government to get funding that was dependent on stigmatising drug users.  (As he put it, ‘Because you are seen as a threat, the government is prepared to spend money on drug treatment.’)

I wonder how many of those former critics would like to go back to those simpler times now?

Thursday, 21 April 2016

Addiction or false consciousness?

I recently read an article about gaming addiction, which inevitably got the usual questions bubbling around my head.  What might this person mean by 'addiction'?  What does this sort of issue have in common with 'drug addiction'  or 'substance misuse'?

If we take the DSM V definition of a substance use disorder, then it's certainly possible to identify that people can play games to the detriment of family and wider relationships, personal finances, career and so on.  And that the activity chosen at some level gives some kind of pleasure or release - even if by the point of dependence that's tinged with guilt or shame, or only amounts to feeling 'normal', not excited, euphoric or 'high'.  That's why I'm never surprised by (or interested in) academic studies or media stories identify how particular activities, or a new substance (such as cheese), stimulate the same receptors as heroin or cocaine.  That's just the body's way of saying you're getting something out of the activity.

So why bother writing about gaming 'addiction'?

Well, the key for me was this article linked this type of addiction with neoliberalism - a brilliant coming together of my two academic interests.  I wouldn't disagree with the writer that lots of people in today's society or economy don't get a sense of meaning, purpose or achievement from their work or wider life.  And that sense of purposelessness doesn't necessarily cause addiction or particular patterns of behaviour, but it can give less of an incentive to break them.  I've just been reading Geoffrey Pearson's The New Heroin Users, and that ends on the note that it's hard to address heroin use in an neighbourhood where use of the drug is widespread and there is mass unemployment.

That unemployment of Lancashire and Yorkshire in the early to mid 1980s could be seen as a direct (even deliberate) consequence of public policy (and let's set aside the fact that the economic policy specifically might be better labelled monetarist than neoliberal).  But it's not immediately clear that 'gaming' addiction is rooted in conditions or policy analogous to this form of (apparently problematic) substance use if the underlying issue is meaning (whether as a result of an unrewarding job or no job at all) or social/community and family connection.

There is certainly a tendency in social policy and related academic fields to say that Thatcherism ripped the heart out of communities, and to link this with close community identity.  And such an interpretation fits with the idea that addiction is a response to a lack of purpose caused by 'neoliberal' economic policy.

The thing is that the image of close-knit communities, held together by work, didn't operate in the same way in all places.  Mining villages were always exceptional in having a single employer, and even the dominance of Raleigh in Nottingham, or Ford in Dagenham didn't represent the life of most people in work under the postwar 'consensus' supposedly destroyed by Thatcher.  There's a reason academics felt the need to conduct ethnography of mining villages, and the idea that 'Coal is Our Life' was a striking title for a book.

This isn't peculiarly 'neoliberal', and might have more in common with the concerns of social commentators and academics in the nineteenth and early twentieth century - people losing their community and social ties (and mores) by moving to cities to take industrial work.  Think of Dickensian tales of London, or Marx's idea of alienation, or Durkheim's idea of anomie.  These were seen to some extent as originating in the division of labour and the loss of traditional community purpose and solidarity particular vocations had given, along with direct, personal, mutual interdependence.  The idea that interactions are based on the nexus of cash owes more to the era of Adam Smith than that of Friedrich Hayek and Milton Friedman.

And this rings true if we think about the history of addiction or substance use.  Public panics about drunkenness were often tied up with broader concerns about the lawlessness of developing industrial cities, and alcohol had a starring role in Engels' description of the hopelessness of life in industrial Manchester.

Misuse of alcohol and other drugs plays a starring role in plenty of literature of the pre-neoliberal world too, notably (though much later than Engels) in the work of Thomas Hardy (at least it's notable for someone who lives in 'Casterbridge').  And computer games hadn't been invented, so we can't find many characters 'addicted' to those.  But we can find people, as in George Eliot's Silas Marner, where a key plot point revolves not so much on a person's dependence on alcohol as what might be called a 'gambling addiction' in modern parlance.  Dunsey's gambling debts as much as his drinking lead him to deception and theft.

And the problems described in literature, media, or medical reports of the period don't sound so different from our own today.  I wouldn't deny that public policy affects the prevalence of misuse, the harmfulness of the consequences, and how easily people can 'recover'.  In fact, I've written about how neoliberalism as an ideology limits the way we approach issues of substance misuse.  But if we label 'gaming' as an addiction, which I might be able to agree with, we can't really see it as a consequence of 'neoliberalism'.  If we do, we risk failing to identify useful, practical solutions.

I have no doubt that many people could live a life more full of 'meaning' - and that, as shown by plenty of addiction treatment programmes, might be achieved as much through religion or philosophy as changing government economic or social policy.  Perhaps it might also be solved, as Marx envisaged, by a communist revolution.  Or perhaps by a return to small, self-sufficient communities as envisaged by the 'Diggers' in the seventeenth century or more recent utopian groups.

But whether that is more desirable than remaining engaged in society as we find it, tweaking our own relationship with it perhaps, and being aware and somewhat detached and cynical is a personal and philosophical question, not one where the causes of addiction are particularly relevant.  (You can perhaps guess where my natural sympathy lies.)

Addiction is more a human failing than one of neoliberalism.  I'm not convinced this search for meaning is something we particularly suffer with under 'neoliberalism'.  In fact, neoliberalism's most vocal critics wouldn't argue that people fail to find meaning under neoliberalism; they just argue that people find it in the 'wrong' things, like consumer products.  And if you're frustrated or sad that people are finding meaning in computer games or trainers, that's not an 'addiction' problem; that's a political or moral problem.  It's when people aren't finding meaning or connection that we can should be talking about 'addiction' rather than false consciousness.

Wednesday, 6 April 2016

Disunity as strength

The government recently published its ‘modern’ crime prevention strategy.  Apart from the bizarre title, given that modernism makes me think more of 1916 than 2016, there’s been some concern expressed that this signifies the end of any joint alcohol strategy.  It seems that alcohol-related crime will now be addressed through this crime prevention strategy rather than something covering alcohol issues as a whole.  And separately HMRC has just published its own alcohol strategy in relation to tax.

As usual, what I want to do here is raise the possibility that this actually might be a more positive development than it at first appears.  The fear from some in the field is that without an overarching strategy for ‘alcohol’ there will be no clear vision for action on alcohol from different government departments.

But why did I just put ‘alcohol’ in quotation marks?  It’s not just because our understanding of this topic is socially constructed – banal as that point is.  It’s that actually we group together issues under the banner of alcohol that don’t necessarily have a lot in common.  I’m not convinced by this banner as a unifying term.

Regular readers of this blog will be bored of me stating that there is a myriad of problems associated with alcohol.  And often that’s all they are – associated with, rather than caused by, the substance.  Those who frequently attend hospital emergency departments often have alcohol misuse disorders, but these are generally amongst several other problems where the line of causality isn’t obvious.  The same applies to many people in alcohol treatment.  It’s not just that seeing them as having an ‘alcohol’ issue is an incomplete picture, it can actively be unhelpful to dissociate alcohol from the other factors in their lives – just think of ‘dual diagnosis’ where substance misuse and mental health teams fail to work together because they see the problem as being rooted in the other discipline.  Recovery from substance misuse in lots of ways isn’t about the substance itself so much as the ingrained behaviours associated with it, and making sure people have the full range of appropriate resources (‘recovery capital’, if you will) to make effective and lasting changes to their lives.

But more fundamentally, even if we were to accept alcohol as at some level the root cause of certain problems, the way in which this happens – and the way in which the people affected understand this – varies hugely.  We know that people are very good at dodging the definition of problem drinking, and this is partly because it’s always easy to point to an ‘alcohol problem that you don’t have, and therefore you can’t be a ‘binge drinker’ or ‘problem drinker’ or ‘risky drinker’ or ‘alcoholic’.

Think of my research, where I was told by a group of people who had been drinking for more than seven hours straight that their drinking wasn’t an issue because they weren’t about to ‘kick off’ like some people would after two pints of ‘Stella’.  Or those who said they weren’t ‘binge’ drinkers and behaved responsibly, but admitted in the same conversation that on the way home from a night out they had set fire to several bins in a park.

This isn’t to condemn these types of drinking, but there’s no question that they would be deemed problematic from certain perspectives, and yet drinkers are able to dodge that classification by pointing to others who are the real ‘binge’ or ‘problem’ drinkers.

I’d suggest this is the curse of thinking about ‘alcohol’ problems.  As I’ve written about addiction before, we can sometimes try to pin down an almost infinite number of problems into one definition.  In the case of alcohol, I don’t think anyone is trying to get that kind of elusive single definition of ‘alcohol’ problems, but the discussion can still have much the same effect.

As John Holmes has persuasively suggested, assuming that the aim of policymakers isn’t abstinence from alcohol or prohibition, public policy would benefit from a debate about what desirable drinking might look like.  There’s a fundamental problem with that idea in this context, though.  An instant liberal (or libertarian) response might be that it isn’t for government to prescribe what desirable behaviour would be; instead it should proscribe activity that is undesirable, defined as being harmful to others.

But in fact, if we’re trying to set strategic objectives, it could be seen as being (unusually for policy) harder to define what is undesirable than what is desirable.  The problem is that even if we could define a single ideal of drinking (and mine might well look different to yours), there would be an infinite number of ways to deviate from this.  It doesn’t get us any closer to understanding that (a) drinking ‘risky’ amounts for health, (b) alcohol dependence, (c) ‘binge’ drinking, and (d) something that might be called ‘alcoholism’ can all be different issues, with different causes, different effects and different solutions.  That’s by no means an exhaustive list, and each individual will have unique circumstances, making the ‘problem’, ‘cause’ and ‘solution’ unique.

But more importantly for my original question of whether it’s worth grouping issues together under the banner of ‘alcohol’, I’m not convinced there’s a great deal to be gained by looking at dependency issues alongside the public health concerns of drinking a bit more than guidelines, alongside alcohol-related violent crime.  These involve different agencies, and different ‘solutions’.

At the risk of repeating myself, that approach offers us an all-too-welcome way of avoiding admitting the problems we might have: at least we don’t have that alcohol problem; which means, of course, that we don’t have an alcohol problem at all.  And that goes for towns, cities and government departments, as much as individual drinkers.  With that in mind, maybe there is some merit in having a crime strategy, a public health strategy, and a substance misuse strategy.  They should all address alcohol-related issues, of course, but maybe there’s a certain strength in disunity.  I’d rather try addressing the ‘alcohol harm paradox’ by thinking about smoking, drinking, diet and physical activity together, than by trying to link up alcohol-related violent crime, recommended drinking guidelines and what should be prescribed for detox.

Friday, 1 April 2016

What do we mean by 'drugs'?

Last week I was at a really interesting conference on psychoactivity and drug policy at Warwick University, and was surprised and honoured to be speaking on the same programme as the likes of Stuart Walton and Toby Seddon.

(Unusually, I was also genuinely impressed by the publicity they included in the conference pack – there’s some great work in the humanities going on there.)

The theme of the conference was prohibition, particularly in response to the Psychoactive Substances Act, which may or may not be implemented in the next month or two.  Given the media coverage of the Act this week, I think it's timely to comment on some of the discussions we had.

(Personally, I can’t see the government not implementing this.  Just because a ‘go live’ date hasn’t been set yet doesn’t mean the policy has been abandoned.)

The position of most people at the conference was opposition to ideas of prohibition, whether from a libertarian or harm reduction perspective.  For me, this debate centred on the concept of ‘drugs’.

Fundamentally, many people’s opposition to current drug policy is rooted in a feeling that it is unjust to have some substances legal and others illegal, when there isn’t a great deal to choose between them in terms of their inherent chemical or pharmacological properties.  Why is alcohol legal and MDMA not?  Chocolate and tobacco, but not cocaine and cannabis?  Julian Buchanan is a particularly vocal exponent of this position, using the phrase ‘drug apartheid’ to describe how some substances are considered consumer products (tobacco, alcohol, etc), others medicines (methadone, morphine, sativa), and others ‘drugs’ (heroin, cocaine, LSD).

At the conference, Toby Seddon suggested that, if we try to understand what that last category of ‘drugs’ means, the only thing these substances have in common is the way they are regulated.  They don’t have similar origins, histories or effects (in terms of either mind-alteration or health harm).  He suggested that any attempt to prompt a rethink of drug policy would need to question that concept of ‘drugs’, which currently simply reinforces the ‘apartheid’, as Julian Buchanan would put it.  If people keep referring to ‘drugs’, then they’re using a category that only functions as a tool to maintain regulatory distinctions between substances – precisely the distinctions they want to question.

An interesting presentation came from Kojo Koram, who offered a reminder of how these distinctions can be entrenched.  The 1961 UN Single Convention on Narcotic Drugs uses the word ‘evil’ multiple times in its preamble (p.23 in the pdf here) – a word that doesn’t appear in the comparable sections of conventions on slavery, or even genocide.  It is this moral framework around ‘drug’ use that helps maintain the status of certain forms of use (whether classified as pleasure-seeking, self-medication, addiction or anything else) as problematic.

Stuart Walton argued that what is required is a public challenge to these assumptions and this framework.  Those in positions of influence should speak and act in accordance with their beliefs while they are in a position to change things; not simply afterwards, once they have safely retired or changed jobs.  And people regardless of their power or influence should be open about their use of substances past and present – as also encouraged by Carl Hart – to help break that association between ‘drug’ use and ‘evil’.

My presentation was somewhat different, but focused on the same ideas: that the concepts we use to understand policy are hugely influential.  Given the tone of the event the night before and the conference itself was strongly against what was defined as ‘prohibition’, and highly critical of the Psychoactive Substances Act, I wanted to present some thinking that might be not simply critical, but constructively critical (thinking of the ever expanding list of rules of drug policy and Robert Maccoun’s suggestion that “Experts like to have it both ways; we hold the government to higher standards of proof than we apply to our own policy opinions”).  I wanted to ask whether there could be a sympathetic interpretation of the Act.

I’m not sure I entirely believe my own case, but I wanted to offer a bit of nuance to the claims being made.  My point was relatively simple: ‘psychoactivity’ has replaced ‘harm’ as the concept by which drug policy in the UK is justified.  ‘Psychoactivity’ might not be easily definable, but it is potentially more transparent and realistic than ‘harm’.

Before the Act, UK drug policy was structured around the concept of ‘harm’, and this is still the organising principle for much reform activity – the claim that we should legalise and regulate, or at least decriminalise, ‘drugs’ in order to reduce the harm to users.  The Advisory Council for the Misuse of Drugs (ACMD) was there to offer the government expert opinion about the relative harms of different substances, which would consequently be controlled to varying degrees using the classification system (Class A, Class B, Class C).

The Act replaces ‘harm’ as a way of regulating substances with ‘psychoactivity’.  Substances would no longer be assessed based on their likely harm to users; they would be banned regardless of harm if they were being bought or sold as having a psychoactive effect.  Of course this would in principle ban alcohol, nicotine and caffeine (not to mention several other substances) so explicit exceptions have to be made.  Originally, I thought this might open out discussion to consider why those substances are allowed and others aren’t – and this has happened in public debate, but the government’s position hasn’t changed.

But my argument in the conference paper was that this position might actually be justifiable based on research from history and the social sciences.  First off, the idea of ‘harm’ from substance use is hugely complex.

It could be harm to others, through use of the substance itself, as in passive smoking, or more indirectly through what Liam Donaldson called ‘passive drinking’.  It could be harm to the user directly – but this could take a variety of forms.  It could be that there’s a risk of death, or perhaps a risk of disability or sickness.  And these risks could be from chronic exposure to the substance, or from particularly severe or problematic acute exposure, or particular patterns of use, or through combination with other risky substances or behaviours.  (Here I'm mostly paraphrasing the discussions about alcohol harm at the recent Alcohol Research UK conference.)  Interestingly, when we think about drug deaths we tend to think about overdoses, while alcohol deaths tend to be seen as due to chronic diseases, the result of heavy use sustained over several years.

So you can see that any attempt to compare the potential harm of different substances is fraught with difficulty.  It will inevitably mean looking at a whole range of factors, and weighting them against each other – as you can see from this attempt by David Nutt and colleagues.  Just look at the sheer number of colours there have to be to identify all those potential harms.

A further complication is that these harms aren’t guaranteed.  As the Police are fond of pointing out in relation to new psychoactive substances, using certain substances might be described (if you’re prone to more than a little exaggeration) as ‘Russian Roulette’.  The key to this is the idea of ‘risk’, the problem being that we humans aren’t terribly good at understanding risk – as shown by the confused debate around the recent new alcohol consumption guidelines.  All this means that it’s difficult to put a single number on the harmfulness of a substance.  And that shouldn’t be a surprise to any historian or sociologist of drugs - though for a slightly different reason.

Think of Howard Becker writing about learning to get high from marijuana; Mary Douglas talking about ‘constructive drinking’; Norman Zinberg talking about drug, set and setting; MacAndrew and Edgerton talking about ‘drunken comportment’; or Dwight Heath on the anthropology of alcohol use.  All these authors note the importance of patterns of consumption and the culture or learned behaviour around substance use in determining both practices and harms.  Of course this isn’t to deny what might be called ‘objective’ effects or harms of substances; the point is that how these translate into harms isn’t straightforward.  When considering the likely harm of a substance in a given society, we should be thinking about the norms around its consumption.

This isn’t an original or blinding insight, but it is worth remembering, as it means that policy can’t – or rather shouldn’t – really be made on the basis of a purely scientific assessment of a substance’s properties.  But what’s that got to do with psychoactivity?  Well, the way that concept is applied in the Act is precisely how Toby Seddon or Julian Buchanan would identify ‘drugs’ in policy discussions: it means all those things that are illegal (or we want to be), since it explicitly excludes alcohol, nicotine and caffeine from the category.

And maybe that’s justifiable, given the evidence around harm and social context.  There’s a legitimate argument that given a society’s history and present circumstances, different substances with ostensibly similar pharmacological properties shouldn’t necessarily be regulated in the same way.  This is the thinking behind dividing societies into ‘wet’ and ‘dry’ in relation to their attitudes to alcohol.  Some societies have developed stable ways of dealing with well-established substances, but might not be able to have the same social control over a new substance.  I think this is a simplification of the different ways in which we relate to alcohol, but it's a pervasive model, and there should certainly be some acknowledgement of the importance of social context to harm.  The point is, policy based on the sociological and historical research on intoxicants wouldn’t necessarily apply a single standard to all relevant substances.  And a scientifically determined concept of harm, based on the inherent properties of a substance, wouldn’t be able to make these distinctions.

If people have quite different understandings of two very similar substances, it’s reasonable to acknowledge those understandings as misguided or irrational – but it would also be rational to control the substances in different ways to take account of the different way people react to them.

In practice, this is how the Government is using the concept of psychoactivity: to designate substances the government thinks, rightly or wrongly, we're not in a position to safely legalise, due to the social context.  (Or perhaps I should say, they're not in a position to safely legalise, due to the political context.)  And based on the scientific, historical and sociological evidence, there is a sense that psychoactive substances have dangers (even alcohol is ‘no ordinary commodity’), and, because of cultural factors, we can’t treat all substances that have the same apparent level of psychoactivity or toxicity in the same way.

This doesn’t mean that the UK government is right to ban MDMA, LSD, nitrous oxide and a myriad of other substances.  But it does make the apparent inconsistency a coherent position.  It is partly historical accident (and as Virginia Berridge and others would point out, a relatively recent historical accident), but there’s no avoiding the fact that currently illegal substances occupy a distinctly different position in our society to those longstanding legal substances such as caffeine, alcohol and nicotine.  Of course the fact that other substances have been legal – or differently regulated – in the relatively recent past suggests that it’s not unrealistic to imagine such a situation could be instituted again.  And that might not be a bad thing.  I’d hoped that those ‘disruptive innovations’ of e-cigs and NPS might prompt a rethink of current drug policy, and to a certain extent it’s disappointing they haven’t.

But to rail against the Psychoactive Substances Act as being incoherent, inconsistent or hypocritical is not only to subscribe to a naively rationalist view of policy, but also to neglect the hugely valuable contribution of history and social science to the study of intoxicating substances.  We can't – and perhaps more importantly shouldn't – rank substances according to some apparently objective, unchanging, ahistorical notion of harm.

That's perhaps an oversimplification of what Nutt and colleagues, and various campaigners have been trying to do, but I'd still suggest that's the frame by which they justify their approach.  And it's not only unrealistic; I'd suggest it's actually undesirable as an ideal.  If alcohol isn't an ordinary commodity, new psychoactive substances are even less so.  So perhaps ‘psychoactivity’ in the new Act is simply a synonym for ‘drugs’ as colloquially understood, as reflects the continuing influence of ‘drug apartheid’ – but we should be careful of extolling the benefits of a pure, objective, rationalist drug policy: there’s plenty of social research that suggests this wouldn’t fit with how we actually understand and use different substances.

It may not be a perfect policy, but let’s not be too quick to dismiss the Act as unthinking or arbitrary.  Maybe the Act, for all the critique, actually presents a more coherent approach to drug policy than ‘harm’, which simply points to an apparent inconsistency between legal and illegal substances.

Update 06-04-16:
You can hear me discussing some of these issues with Steve Harris of BBC Radio Solent on their 'Breakfast in Dorset' programme on the day the Act was meant to be introduced - but wasn't - here.

Friday, 18 March 2016

Individuals, society and desirable drinking

I spent a great day on Wednesday at the annual Alcohol Research UK conference.  There was a huge amount of evidence on show, and discussion about the nature of evidence-based policy, how research can produce impact and shape policy.

The discussion really boiled down to whether there could be a common language, and genuine communication between researchers and policymakers.  There was consideration of all the usual themes of academics being cautious about their conclusions, and working over long timescales, where politicians want the 'killer' study that gives them a definitive answer to a policy problem.  In fact, there's a point to be made that researchers too are looking for that perfect answer.  We isolate factors, control for variables, and try to identify causes.

Tom Parkman got to the heart of things in the final session, raising the question of whether alcohol was the cause of various problems, or whether the drinking was the result of (for example) housing, employment or relationship difficulties.  He described this as the 'chicken or egg' conundrum, but that's really a shorthand for the fact that these issues are mutually reinforcing – as he suggested, once problems are established and chronic, is there any value in identifying which came first?  It might be more helpful just to get on with an intervention that addresses problems as they stand now.

And actually researchers aren't great at this.  We can trot out 'complexity', but still don't often manage to move constructively beyond that to conclusions or suggestions that are relevant to policymakers.  It's no good responding that things are more complicated than policymakers would like, unless we can offer an alternative interpretation or proposal.

How do we represent that complexity?  Often a quantitative study identifies the specific contribution of alcohol to a 'complex' problem, as if then a controlled intervention can singly address the alcohol issue, while some other intervention or organisation deals with the bit that relates to housing, or employment, or whatever else has been controlled for in a regression analysis.

Qualitative studies often conclude by metaphorically throwing hands in the air and suggesting (correctly, but not always helpfully) that 'it's a bit of everything'.  The problem is 'complex' or 'wicked'.  And we tend to invent our own terms to try to make sense of things.  There's any number of typologies of drinking patterns – but how have these been translated into interventions or policy?

Here's where the fresh eyes of a more quantitative team were helpful.  John Holmes described some new work from the famous Sheffield Alcohol Research Group analysing drinking diaries to identify particular forms of drinking occasion, offering much-needed contextual data (but in a systematic way) to the overall consumption data that tells us only amounts and frequency.  I can see their typology of drinking occasions being genuinely useful – taking the work of Mark Bellis' team to the next level.  It's an example of acknowledging the situation is complex, and can't be accurately addressed with a single 'killer' answer, but still providing something that you can imagine being communicated to a policymaker.

But John closed his presentation by raising another key issue.  We know that 'harm' isn't easily defined, and we know that even if we do define it very tightly, we can't make a totally straightforward link between consumption and that harm.  We need that contextual information, about quantity per occasion, and other factors such as whether food was present, family or friends, and so on.  That is, harm isn't simply dependent on consumption levels; it's affected by drinking cultures.

So if we're not going to simply aim for prohibition or zero consumption of alcohol – if we're prepared to accept, as most people in the room seemed to be – that there could be positive, or neutral alcohol consumption, we need to define what a 'desirable' drinking culture might be.  What 'should' policy be aiming for?

And in the context of references to sociology and social anthropology, that makes complete sense.  There is no doubt that drinking 'cultures' affect harm, as well as simply consumption levels.  Sociologists by definition are interested in studying society, as much as individuals.

But policymakers aren't all sociologists.  The analysis doesn't simply translate into policy, as we heard so often during the day.  In this instance, it's because of a frame that defines what is appropriate for government to do.  We could argue over what a desirable drinking culture might look like, but that's a second order question.  First we'd need to have agreement that government be in the business of fostering 'culture'.  This would sit at odds with Margaret Thatcher's reasonable (and selectively quoted) statement that 'there is no such thing as society'.  This plain statement was actually very sensibly qualified by the observation that there are individuals and families.  This is really a claim about the appropriate unit of sociological and policy analysis: should we look at groups of people (who are only 'latent' classes, to use the terminology of John's paper) or should we look at the individuals themselves.  (I'd quibble with Thatcher's assumption that families are not a concept that needs unpacking, but that doesn't challenge the overall approach.)

It is an unavoidably political discussion not just to define what an acceptable drinking 'culture' is, but to even suggest that government should be thinking at the level of 'cultures'.  Much as I'm sceptical of the utility of the term (although it's been very useful in getting me publications in academic journals), this is a questionable claim while (if?) we live in a neoliberal political environment.  According to that orthodoxy, the unit of analysis is the individual.

And in fact, that's an appropriate place to end and bring this post full circle.  An individual, as Bauman pointed out, originally means something that is indivisible.  And that individual, as Tom Parkman's research suggests, can contain plenty of interacting factors (housing, employment, physical health, personal relationships, mental health, drinking practices etc etc).  But they are indivisible.

And, echoing Wulf Livingston from Tuesday's symposium, perhaps that's where we should start and finish: what does desirable drinking look like, not to policymakers, or public health professionals, or academic researchers, but to drinkersand the wider public themselves.

Saturday, 20 February 2016

Michael Gove, Power, and the EU

I don’t often blog on general themes of politics here.  Mostly, I stick to issues relating to alcohol and other drugs.  That’s simply because that’s the area I know best, on which I spend the most time.  But the original purpose of the blog was to discuss public policy issues where I felt there wasn’t clear debate.

I’ve talked about university admissions before, but this time I’m going to touch on the EU referendum.  Not to get into the substance; I simply don’t know enough about that.  But to apply some relevant understanding I do have (of political and sociological theory), to suggest that the debate risks missing the point.  I’m specifically going to discuss Michael Gove’s statement on why he will be campaigning for withdrawal from the EU.

The whole argument, it seems, comes down to his worry about his own personal power.  ‘It is hard to overstate the degree to which the EU is a constraint on ministers’ ability to do the things they were elected to do, or to use their judgment about the right course of action for the people of this country.’

This might be a fair enough point, if it was making the case that decisions should be devolved closer to the people they affect, and that a UK minister is another step closer to the people of their country than an EU politician.  Certainly there’s a sense in which the UK government has more control over UK policy than EU-wide policy.

And this is to some extent the fundamental issue: how small should units of government be?

(On this point, Gove makes a disingenuous comparison with the United States, suggesting that just as they fought for their freedom through the War of Independence, we should take our freedom from the EU.  Given the role and autonomy of states within the union, a case could be made that in terms of distance from voters’ lives, the federal government has in much in common with the EU as it does with the UK government within that EU.  To take slightly flippant examples from my field, the legal status of different substances, like cannabis, and the age at which you’re allowed to buy alcohol vary by state in the US, and nation in the EU.)

But this question of how close power should be to citizens betrays Gove’s simplistic approach to power.  This might well be a trick to make his argument more persuasive, but as I write so often on this blog, that might be even worse than if he genuinely believes what he is saying.

There is not, cannot be, and never has been a situation where a minister in Whitehall – or any other person ‘in power’ – can issue commands that are simply enacted.  This is partly because of ‘street level bureaucrats’, who will actually be implementing any policy or diktat, but it’s also because the idea of ‘control’ that Gove seems to envisage is impossible.

He states that ‘government is not, ultimately, in control in hundreds of areas that matter’ – but this is not the result of the EU; it’s the inherent nature of power.  The EU is a useful scapegoat, but no government has ever had ‘control’ of the economy, for example.  Even if it left the EU and took back direct responsibility for setting interest rates, the UK government would not be able to magically command employment, wages and growth rates.

But perhaps if Gove doesn’t mean controlling the outcomes of policies, or even their implementation, he simply means ministers should have autonomy in setting policies.  In reality, though, this too is a charade.  The world in which ministers could say ‘this is what our policy should be’, and it could be implemented, is impossible.  Their choices are constrained by a myriad of factors, from international governments and corporations to sectional and electoral interests at home.

Of course, that’s the nature of politics: to look at a range of arguments and interests and come to a compromise.  And it could be that’s the vision of politics that Gove is aspiring to: his ministerial compromises will be better without the institutions of the EU involved.  His judgement will be improved by making a political calculation about the informal or putative constraints posed by the European context, rather than having formal constraints already written out.  (Of course he’ll still have to pay attention to the European Court of Human Rights, but that’s another story.)

In a sense, though, that’s less transparent for the voter.  If he can identify why he can’t enact a particular policy (it’s EU Directive X) that might be clearer than if he had to explain how that policy might spark a response from other countries, and he’s calculated it’s not a risk worth taking.

But all this is a sideshow.  For all that central government talks of a new approach to governing and commissioning that focuses on ‘outcomes’ and not processes, Gove’s thinking is all about process.  We should be having a grown-up debate in which the EU is understood to be just one (unusually clear-cut) constraint on ministerial decisions amongst plenty of others, and where there’s an acknowledgement that in any case ministerial decisions have a long way to go before they affect people’s actual lives.

Maybe then Brexit is the answer.  It would remove what is often a diversion from the real constraints and issues in politics, and might force politicians to admit that Gove’s statement is truer than he would admit: ‘your government is not, ultimately, in control in hundreds of areas that matter’.

That’s quite a price to pay for a ‘told you so’ feeling.  This vote isn’t about simply taking ‘control’.  It is at best opportunity to swap one set of constraints for another – and that makes it even more important we talk honestly and openly about what those constraints are and might be.

Wednesday, 3 February 2016

Thinking beyond population harm and addiction

I often mention on this blog the range of problems that are associated with alcohol, and how this can muddy the waters when we try to discuss alcohol policy: are we worried about violence and antisocial behaviour linked to ‘binge’ drinking; health and social problems resulting from addiction or dependency; or the risk of health harm due to long-term use?

James’ diagram showed a summary of how alcohol problems have been understood and the dominant policy approach taken by campaigners – for example, a belief in the 18th century that spirits produced a new and dangerous type of drunkenness, and therefore that they should be specifically controlled (and perhaps beer consumption encouraged instead).

The example given for policy today was that campaigners have moved away from focusing on addiction as a disease (and therefore targeted treatment as a solution), towards a preference for understanding alcohol problems as being on a continuum, and the appropriate solutions as being focused on the supply of alcohol (e.g. price and availability).

The only problem with this way of thinking (and I’m not criticising James, just the public debate he’s analysing) is that if there’s a whole continuum of alcohol-related problems, it seems odd to focus on availability as the solution.

There is a strong argument that reducing availability affects use and therefore to some extent the scale of social problems associated with substances.  A key reason (though not the only one) why there aren’t that many heroin users in Britain, and there are far fewer heroin-related deaths than alcohol-related deaths is that it’s not as easily available.

(Of course heroin us isn’t as socially acceptable as alcohol use, but again the two things (availability and a culture of consumption) are linked: alcohol is available all over the place – and supported by politicians as an industry – because it’s socially acceptable, but it’s acceptable (or normal) partly because it’s so visible and available.)

But all that doesn’t mean that availability is the only game in town; it’s certainly not what most drug campaigners focus on.  Whether you have a relatively free market in substances, one that’s reasonably well-regulated, or one based around prohibition, you’ll still have people using substances who need some form of help to reduce the health and social harm caused by their use.  Current treatment services in the UK have plenty of users of both alcohol and heroin.

You can call that level of use ‘addiction’, or ‘dependency’, or ‘heavy use sustained over time’, or you might be thinking of ‘risky single occasion drinking’ – and all those might describe genuinely different patterns of use that imply a need for different sorts of support.

And that’s where the debate in the UK has fallen down.  There’s a tendency to leap to see either the substance (alcohol) as the problem, or identify particular people (alcoholics, drunks, or whatever label is in fashion) as having weaknesses or vulnerabilities to it.  In the 20th century stage of James’ model, although it isn’t seen as a person’s moral failing, particular people are picked out as having a ‘disease’.

There’s always an issue around stigma, though, when you focus on individuals.  Kettil Bruun argued that focusing on populations was a neat way to get around this – and you could still implement interventions on this basis that were effective for those most in need of help.

Some current commentators on substance use (notably Johann Hari) have tried to bypass this debate by plonking down (without admitting it) the old sociological concept of ‘structure’ to replace the ‘agency’ of the individual who might have a problem.  That is, it’s suggested that the problem doesn’t reside in particular substances (and people often replace an ‘addiction’ to one substance with some other form of addiction – to activities like shopping, sex or gambling as much as substances).  Instead, with frequent reference to ‘rat park’, the wider social environment is seen as the problem: people who have issues with substances variously need ‘jobs, friends, houses’ or social ‘connection’.

In reality, this doesn’t get us out of the debate on whose ‘fault’ addiction is, as any sociologist who’s tried to write about structure and agency would be able to tell you.  (Don’t get me started on Anthony Giddens and ‘structuration’.)  The reality is bound to be more complex, where some people’s issues will be primarily down to their social environment, others a genetic predisposition, others simply to the risks inherent in alcohol consumption, where they didn’t particularly have any other warning signs.  Most are a combination of a whole range of factors.

And this formulation still leaves us focusing on a particular cohort of people: those who are (whether we use the word or not) ‘addicted’.  And even if you’re not saying that individual has a moral or genetic ‘failing’, there’s still something stigmatising about pointing out which group in society is in greatest need of jobs, friends and houses, and social connection – and there’s a danger this plays into certain damaging narratives around ‘sink estates’.  When you hammer home the importance of wider social structure, there’s not much ‘agency’ left to that individual to find meaning and stop feeling powerless in their own life.

But what’s this got to do with intimate partner violence (IPV) and yesterday’s conference?

Well, you can see the ‘jobs, friends, houses’ narrative as having just the same aim as Kettil Bruun’s population-wide approach: make sure resources are there for those who need them most.  Only in this case, it’s a response to the fact that the population-level approach seems to be shifting attention from those with the least ‘recovery capital’ to those with the most: brief interventions and universal efforts to reduce everyone’s consumption just a little bit.  By reminding us of the need to focus interventions on those who actually need jobs, friends, houses, we can target scarce resources most effectively.

(I should point out that this is only my speculation on the motives of some who’ve made these claims; probably not Johann Hari, who’s more concerned about stigma and a more liberal drugs policy.)

But as we talk about jobs, friends, houses (I know it’s getting tedious repeating that phrase) we’re really just talking about ‘addiction’ or ‘alcoholics’ in a new language.  We’re still focusing on one particular segment of a broader spectrum of problems.  And that poses a big problem for some of the possible responses to IPV that were discussed yesterday.

It was pointed out that while programmes to treat perpetrators of domestic abuse mostly run through criminal justice services, only a small proportion of those who commit these acts come into contact with the criminal justice system, and still less for these specific crimes, which is how people come to be referred to these programmes.  By contrast, a high proportion of those in substance misuse treatment admit to having committed IPV (though they wouldn’t necessarily see this as a crime, particularly where it doesn’t involve physical abuse).

This is the logic for hosting such programmes within substance misuse treatment services, or at least referring people through them.

And research with the partners of perpetrators that was presented at the conference by Ingrid Wilson suggests that alcohol is indeed closely related to IPV.  (And I have to say I thought her model of the stages of drinking and IPV was one of the best results of a grounded theory type approach that I’ve seen.)  But I’d suggest that the drinkers described by their victims had more in common with ‘binge’ drinkers – or perhaps those who engage in “frequent occasions of heavy drinking that [also] result in heavy volume drinking”.

If we really think there is a continuum of harm in relation to substances (and alcohol in particular), then we need to think of a full continuum of interventions.  And that means having more nuanced discussions than we do now.  Binary thinking might help frame some discussions, and will win some arguments, but it can’t give the full picture, or provide a complete answer.