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 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 need to cut me some slack here.  I’m not 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.

Tuesday, 24 July 2018

Binges, bouts and gaps in treatment

I’m going to suggest in this post that the approach of alcohol policy and treatment in the past few decades has had a crucial blind spot.  As ever, it’s not peer-reviewed research, so what you’ll find is the usual mix of personal and professional experience, in this instance prompted by literature.

This is a relatively short piece and isn’t meant to be watertight or academic.  It doesn’t go into the full debates around definitions of dependency, addiction, alcoholism, substance use disorder, etc.  I just hope it’s useful and can be judged on its merits (or lack of them).

I’ve written before about how definitions of problems associated with alcohol change over time.  The characteristic drinker seen as having a problem in the nineteenth century wasn’t doing the same things as someone we might see as having a problem in the 21st century.

I have to confess I get most of my feeling for this from fiction.  I say ‘confess’ as if I feel guilty about this.  I don’t.  (Though I will be making a reference to a proper confession in a minute.)  There’s plenty of histories of the concept of ‘alcoholism’ or ‘addiction’, and I’m not the person to write more on that; I’m certainly no historian of medicine.  But I have read my fair share of scientific definitions of problem drinking.  In fact, those studies have set for the scene for my thinking based on fiction.

When I was starting out studying ‘binge’ drinking (as defined by the media – i.e. getting drunk on the night-time high street), I naturally wanted to know if there was a ‘real’, ‘scientific’ definition of a ‘binge’.  At the time (2006) there was quite a bit being written about how the idea of ‘binge’ had become a ‘confused concept’ in contrast with a time when it had meant something more specific to the likes of Jellinek when discussing a technical definition of ‘alcoholism’.  And perhaps rather than a ‘binge’ we should have been referring to young drinkers as having ‘bouts’ of drinking.

Basically (and here I emphasise again that I’m no scientist, or medic, or medical historian), a ‘binge’ in old-school parlance meant a period of several days when someone fell off the wagon quite spectacularly.

And here’s where the literature comes in.  One of the most famous examples is The Lost Weekend – the drinker goes through periods of sobriety, before going on a binge, which comes to a natural conclusion in a detox (either in hospital or at home) after period of extreme drinking has run its course.  (I’ve never seen the film, only read the book, so apologies if this doesn’t fit.  Interestingly, the Wikipedia page for Charles Jackson refers to ‘his binge drinking’.)

You can see the same sort of theme in nineteenth-century descriptions of ‘drunks’ – who don’t spend all their time drinking, but get drunk with serious consequences.  Think of Joseph Poorgrass in Far From The Madding Crowd, who it seems can go a long time without a drink, but when he does have one, it ends up being more.  He even takes the opportunity to stop while driving a coffin back from town, parking it up outside the pub

I want to suggest that in some ways we’ve lost sight of this form of trouble with alcohol.  Or perhaps just treatment services and policy people have.

At first sight, this references might seem like classic forms of ‘alcoholism’, following the AA definition.  Someone who has, as I once heard it described, ‘got the spots’ can’t have just one drink – though they might go years without any.  One drink always leads to ‘too many’.  And this is how a lot of people who would see themselves as ‘sober’ or ‘in recovery’ would define their problem with alcohol.  Check out Laurie McAllister’s blog, particularly the contributions from a range of other people.

But I don’t think this is quite how professionals and policy people look at the world.  I would suggest that there seem to be two definitions of problem drinking in the UK today – or perhaps England more specifically.

I want to think about how the problem is defined.  First, there’s the idea that lies behind unit guidelines: drinking alcohol increases your risk of certain illnesses like cancer.  This is what means we have stats on low, increasing and higher risk drinking.  This discussion of drinking isn’t about whether people currently have a ‘problem’, or are suffering ill-effects from alcohol; it’s about whether people are putting themselves at risk of developing problems in the future.

Second, it seems that alcohol policy doesn’t really talk about ‘alcoholism’ much any more.  Instead, to convey the idea of a group of particularly heavy drinkers, the statistics talk about ‘dependent’ drinkers.  This means that you’re drinking at a level where your body has become physiologically dependent on alcohol, and withdrawal will have a harmful health impact that probably needs to be managed with medication.

And this isn’t just about the stats.  Consider how we think of an alcohol problem that needs treatment (as opposed to a ‘brief’ or ‘behaviour change’ intervention that groups alcohol with other issues like diet and exercise).  Generally, we’re referring to someone who drinks every day and has a level of dependency.  That classic question in the screening tools of whether you drink every day, or even have drink in the morning to get yourself going.  What’s the treatment available?  Detox.

I’m not saying that everyone who engages with community treatment services could or should have a ‘detox’.  However, there’s no getting away from the fact that that element is the most clearly defined and regulated.  Prescribing for withdrawal is in many ways more straightforward than trying to identify what ‘talking therapies’ or other interventions might foster ‘recovery’.

I don’t have a reference to cite here.  This is my individual reflection on how treatment services are organised today.  There are two prongs of structured treatment, according to the national database: pharmacological (prescribing) and psychosocial (talking therapies).  This is partly the legacy of a system that was set up to capture the work done to treat opioid use disorders, where prescribing is such a central part of the standard model, but it does to some extent reflect how we think about these systems, and how we commission services.

But think back to those accounts on Laurie McAllister’s blog, or Joseph Poorgrass.  They don’t drink every day.  But alcohol is still a problem that needs something more substantial than a ‘have a word’ approach of: ‘have you thought about drinking a bit less?’

So should we be treating people who have ‘binges’ or ‘bouts’ of drinking?  This idea actually makes me feel uncomfortable.

Why?  I think it’s because this drinking to oblivion is often seen as dysfunctional or maladaptive by definition.  Deliberately drinking to drunkenness, whether called a ‘binge’ or a ‘bout’ is indicative of some kind of underlying problem.

My work on ‘binge’ drinking reframed it (as have other people) as ‘carnivalesque’, to try to convey that it is ambivalent for all concerned, whether producers, drinkers or government/regulators.

And this ambivalence struck me again over the weekend, reading Doris Lessing:

Mr Clarke earned fifty pounds a month which was more than he would earn anywhere else.  He was a silent, hardworking man, except when he got drunk, which was not often.  Three or four times in the year he would be off work for a week, and then Mr Macintosh did his work for him till he recovered, when he greeted him with the good-humoured words: ‘Well, laddie, got that off your chest?’  ‘The Antheap’, Five, p.193

He [James] would get really drunk several times a year, but between these indulgences kept to his three whiskies at sundown.  He would toss these back, standing, one after the other, when he came in from work; and then give the bottle a long look, a malevolent look, and put it away where he could not see it.  Then he took his dinner, without pleasure, to feed the drink; and immediately went to bed.  Once Paul found him at a week-end lying sodden and asleep sprawled over the table, and he was sickened; but afterwards James was simple and kindly as always; nor did he apologize, but took it as a matter of course that a man needed to drink himself blind from time to time.  This, oddly enough, reassured the boy.  His own father never drank, and Maggie [his mother] had a puritan horror of it; though she could offer visitors a drink from politeness. It was a problem that had never touched him; and now it was presented crudely to him and seemed no problem at all.  ‘Eldorado’, Five, p.171

In both of these instances, like Paul in the second extract, I find it hard to see that there’s much wrong with these men’s drinking.  Perhaps, given the fact that Mr Clarke has lost other jobs because of his drinking, and James obviously has some kind of ‘malevolent’ feeling towards alcohol, this isn’t an entirely healthy relationship, but then all of us do (or fail to do) things that other people would see as unwise or unhealthy in the long term.  (I’m reminded of the Church of England confession with its call to sobriety: we’re all ‘miserable offenders’.)

And it’s partly this need to distinguish heavy drinking from problematic drinking that’s made the medical model so attractive: dependence is a diagnosis without judgement; it’s about physiology.

And at this point the disease model of alcoholism/addiction is relevant.  A disease is a medical problem, and it feels natural to us to treat a disease with medicine – hence the idea that a physiological detox is the core treatment for alcohol problems.  And it is in fact a highly effective, evidence-based treatment for physiological dependency.  But dependency is not the same thing as ‘alcoholism’, and even if we just talk about ‘the disease concept of alcoholism’, remember that Jellinek stated: ‘The subject of this study represents not more than a small section of the problems of alcohol – a very small section indeed.’

And here’s the rub: we can never have a clear, objective definition of an alcohol ‘problem’ based on actual drinking behaviour unless we’re prepared to group Joseph Poorgrass and Mr Clarke together.  They both drink, occasionally, to oblivion, but one does it in a planned way, as a holiday; the other does it while he’s transporting a coffin, complete with corpse.

It’s true that this could be captured by elements of the DSM definition – the fact that Joseph Poorgrass’ drinking does damage his work, for example.  But I want to suggest that in practice it’s really hard to actually distinguish between this and the drinking by James in Doris Lessing’s ‘Eldorado’.  I know this is the purpose of tools like AUDIT and SAD-Q, but here I just want to question this pseudo-scientific approach, and wonder out loud as to whether this medicalisation of alcohol problems is actually helpful.

That is, we have a tendency to look back in time and think that terms like ‘drunkard’ were unscientific and unhelpful, and even stigmatising.  We now live in a more scientific and less moralistic world with our ideas of disease and dependency.  But my question is: does this comfort of apparent science and objectivity mean that we fail to offer support to everyone who needs it?

As I said at the beginning, this isn’t a peer-reviewed, evidence-based piece.  It’s just some reflections on my recent experiences, prompted by reading for fun.  Maybe I’m wrong about the nature of ideas of disease and dependency and medical models of treatment, and their influence on services today.  I’d love to know what other people’s thoughts and experiences are.