Monday, 11 May 2020

Policy change to address COVID-19

This is the first time I’ve blogged here since COVID-19 really hit. 

If you’re interested in broader reflections on what the crisis might mean for alcohol policy, I’ve written about that for the wonderful Drinking Studies Network here. 

But here I want to identify four specific areas where I think policy change or government guidance could be game-changing for people receiving treatment for issues with substance use.  This doesn’t mean they’re the most important areas of activity or policy at the moment; to be honest keeping on doing the ‘bread and butter’ tasks of substance misuse treatment is the core challenge.  But these are the issues where I think the biggest change could be delivered by relatively simple, almost technical, interventions.  These changes aren’t about the detail of delivering treatment so much as freeing people up to deliver support in the most efficient and effective ways we can manage. 

(1) Buprenorphine and (2) the supervision of medication 
First, I want to talk about buprenorphine.  This is one of basically two drugs recommended to as part of opioid substitution treatment (OST), which means people can avoid withdrawals from heroin (or other opioids) and not have to think about funding their habit, as they’re prescribed medication.  The evidence is strong that these interventions reduce crime and the transmission of blood-borne viruses. 

In normal times, lots of people on OST attend a pharmacy every day to be supervised taking their medication.  This helps ensure that (a) they’re definitely taking it and getting the specified dose; and (b) they’re not having any kind of adverse reaction that means the dose needs tweaking. There’s also a valuable safeguarding role: the pharmacist is seeing them in person and so can see any broader deterioration in health or make a judgement about potential wider issues, such as domestic abuse. 

But there’s a downside to this level of supervision during COVID-19.  Going into town every day increases your risk of catching COVID-19, and the pressure on pharmacies a few weeks ago meant that there were queues as well – at best simply off-putting, and at worse further increasing your risk of contracting the virus. 

So the solution introduced (often well ahead of formal government guidance) was to balance up those risks and ask people to attend pharmacies in person less often than they would normally.  This might increase other risks, of course.  If you’re taking home a whole week’s worth of medication rather than just a day or two, then there’s a greater risk of overdose if you take it all at once, or it could be used as a tool of control by an abusive partner or organised crime group. 

Treatment providers are aware of these risks, and are making decisions on a case-by-case basis, balancing up those risks against those of catching COVID-19, particularly given that lots of people in treatment may already have complicating factors (like hepatitis or COPD) that make them more vulnerable.  And commissioners like me are trying to keep a track on all of this to see if we’ve got the balance right.  (Maybe if pharmacies aren’t so busy, a few of the clients more at risk should have face-to-face contact a bit more often again?) 

One of the other ways we’re managing these risks is to make greater use of buprenorphine, one of the key OST drugs along with methadone.  Generally, in line with national guidance, most people in treatment are prescribed methadone, as it’s cheaper and easier to supervise (drink a liquid rather than dissolve a pill under your tongue), and there’s no any clear evidence buprenorphine delivers better outcomes – in fact, in the early stages methadone seems to keep more people engaged. 

So why use more buprenorphine?  Well it’s less risky if you’re taking it home in larger quantities, as there’s less risk of overdose and less to be gained by using heroin ‘on top’ of your medication. 

And this is exactly what the guidance from Public Heath England, issued a few weeks ago, recommends.  The challenge, though, that buprenorphine is considerably more expensive than methadone, and it costs about seven or eight times as much as it did a couple of years ago.  Some very rough local modelling suggests switching someone from methadone onto buprenorphine costs over £1,000 extra per year.  That might not sound like much till you scale it up: a small shift in a client base of 1,000 (not unusual in large local authorities) will cost £100,000s.  Not easy to find at a time when local authorities are losing large sums every week. 

Of course buprenorphine in its conventional tablet form isn’t the only option; it could part of a range of changes we could make. 

One would be to introduce, as has been done in Wales, ‘depot’ buprenorphine, which works like some long-acting reversible contraception injections: it gives a steady dose of the drug over a week or a month, gradually dissolving – meaning you have stability, certainty, and have to see a nurse or pharmacist less often.  The COVID-19 guidance states local areas could consider this, but resource requirements (amongst other things) will probably make this challenging.  We’re certainly considering this locally, as we have been for a few years (we were hoping for guidance from NICE/PHE this spring, though that’s now clearly not going to happen). 

Another, simpler option, is to introduce delivery of medication, which allows services to still see patients eye-to-eye.  We’re doing this in Dorset and BCP, but at the moment we’re reliant on drivers from other areas of the council, and they don’t have the expertise to offer any kind of clinical judgement as pharmacists might, so we’re both vulnerable to those staff being reallocated, and we need to ensure we’re providing specialist support where necessary.  Both of those will cost money. 

One solution could lie in community pharmacies.  This whole issue of switching people to buprenorphine arises because people aren’t being seen in person so often.  Given that we pay pharmacies for each time they see a client, then surely we’ll have some savings on that ‘supervised consumption’ budget?  Wrong.  In the same section where PHE recommends moving people onto buprenorphine so they don’t have to come into the pharmacy, it also states that local authorities should carry on paying pharmacies their standard amounts for supervised consumption even if they’re no longer doing this as much. 

This makes sense: we don’t want pharmacies to struggle and close, and it’s an accepted principle in the NHS response to COVID-19.  But local authorities aren’t funded like the NHS, and the additional funding being offered by central government is unlikely to meet these costs (if it even makes its way to public health departments). 

So those are my first two asks.  If the government is recommending we keep paying pharmacies while still requiring us to find alternative ways of delivering this kind of supervision, then it needs to find that funding.  And if it thinks generic buprenorphine is a solution, then it would need, again, to find the funding for that. 

I know this might sound like the typical call for ‘more money please’, but these aren’t areas where ‘efficiency’ can solve things on its own.  Buprenorphine and trained staff time simply cost money, and we’re being asked to deliver more of them without being given the means to do so. 

(3) Electronic prescribing 
But if efficiency on its own isn’t the answer, that doesn’t mean we’re not looking at trying to be more efficient.  One of the most surprising things about OST services today is that most of them are still doing their prescribing on paper.  Every one of the, say, 1,000 clients in an area needs a new prescription every fortnight.  This has to be created on an electronic system, printed out, signed by a nurse or doctor, delivered to a pharmacy, stored by the pharmacy and then sent off the NHS Business Services Authority so the pharmacy can claim back funding.  For almost every other medicine all this can be done remotely.  The prescriber creates a prescription on the electronic system, presses send and it appears in the pharmacy on their electronic system.  No printing, no signing in person. 

This sounds inefficient, but in a time of COVID-19 it’s more than that; it’s risky to staff.  The admin staff involved in printing, and the prescribers, all have to share the same office.  Perhaps they can work out a relay system, where people only come in on certain days, but they either have to come in, or the paper (with possible associated infection risk) has to make its way from the printer in the office, to their house, and back out to the pharmacy.  Not practical.  Someone who is self-isolating or shielding, even if they’re currently fit to work from home, can’t. 

There’s been legislation in place since 2015 that means things don’t have to be this way.  Controlled drugs can be prescribed electronically.  The challenge is that this hasn’t been technically applied to ‘instalment’ prescribing.  That is, you can only send through a prescription that involves one interaction between patient and pharmacist, when (in normal times) most of our prescriptions involve people attending more than once a fortnight.  In fact, even in COVID-19 times, most people are still collecting their medication at least weekly – which would mean they’d need a new electronic prescription every time. 

You might think that’s just a technical problem, and still easier than all the paper we use now, but every prescription can of course carry a prescription charge, so if I’m suddenly having to pay every week rather than every fortnight you’ve just doubled my costs as a patient. 

And this isn’t just about the patient; it’s about the pharmacy again.  Often (and particularly in these times) even though they’ll have one ‘prescription’ and they’ll be giving a week’s worth of medication to someone, this won’t simply be as a single bottle of methadone – the safer, easier option is to sub-divide this into seven, pre-measured doses.  And the pharmacist gets paid different amounts, quite rightly, depending on whether they’ve done this pre-measuring or not.  If it’s just one prescription, with no guidance about those ‘instalments’, then they can only be paid the standard amount. 

I’ll repeat that this is a technical, not a legal, problem – and one that can’t be solved by local areas; it’s a national issue, effectively with IT. 

(4) Supplying alcohol 
Finally, and briefly, supplying alcohol.  Suddenly stopping drinking can have serious health risks if you are dependent on alcohol, so the PHE guidance quite rightly notes the risks of people struggling with alcohol supply in a time of COVID-19 if they’re dependent.  If someone is short of funds, or self-isolating, they may struggle to get hold of alcohol, and therefore unintentionally put themselves at risk. 

Local treatment services can of course support people through this process and assess their needs, but it’s not clear from the guidance whether they’re also meant to be helping people get hold of alcohol.  And if they were, there’s a downside: unlike with buprenorphine, for example, there aren’t clear processes and guidance on the ‘prescribing’ and ‘dispensing’ of alcohol.  But PHE hasn’t issued any either; it’s just said people should make sure they continue to drink.  Lots of areas are developing their own protocols, but these are all slightly different, meaning that there is local variation without necessarily any need.  There is much more to say on this, but that’s probably enough for now: I would welcome national guidance on who is best placed to do this, and how. 

So there you have it.  Four policy asks: 
  • Funding for continued payments to pharmacies 
  • Funding for buprenorphine or similar approaches to reduce risk of overdose and COVID-19 
  • Prioritising electronic prescribing for OST 
  • Policies/guidance for providing alcohol to dependent drinkers who can’t access it. 
I’m not saying we can’t do anything on these – in fact we’re working hard to take all of them forward.  But they’re all areas where central government intervention could make all the difference.  I don’t just mean government could make my life easier; I mean government could actively save lives. 

Thursday, 16 January 2020

Drug policy and scientific morality

David Nutt is in the news again, talking about the dangers of alcohol (and incidentally promoting his book).  He was on Radio 5 this morning, I think, but this piece in The Guardian offers a good summary of his current position.

I’ve written before about the idea of single ‘harmful’ scores for individual substances and how I find them unhelpful – not just because they’re simplistic, but because they perpetuate a particular approach to drug regulation that I think is naïve and therefore gets ignored.

But I just want to highlight a particularly odd position David Nutt takes in this article.  He suggests that people should share a pint of beer, as just 5g a day is the ‘optimal’ dose.  This is less than a UK ‘unit’, and works out (apparently), as about 40ml of wine – less than a fifth of a large glass you’d be served in a pub or a restaurant.

Even though it's been suggested focusing on this is misleading, as it's likely to have been a throwaway comment used as an illustration, the article has been endorsed by David Nutt - and more importantly it's a revealing, and inconsistent comment.  But at least it’s consistently inconsistent.

As a campaigner for drug policy reform, David Nutt acknowledges the desire to take ‘drugs’ – indeed he proposes that rather than seeking a world in which people don’t use alcohol, we actively create and regulate an alcohol-like intoxicant that is less harmful, and allow people to use this.

Apart from the fact that this proposed ‘alcosynth’ relies on an assumption that we can create and adopt a genuinely new substance to take the place of something that has been part of society since before we were human, the rationale for trying sounds like pragmatic harm reduction: acknowledge an impulse to get intoxicated, and rather than ignoring it or pretending it can be legislated out of existence, provide a safer way that it can be satisfied.

Yet suggesting an ‘optimal’ dose of 5g doesn’t do this.  This is only ‘optimal’ if you don’t want to be intoxicated.  And here we get to the nub of so much alcohol policy discussion: we bring our own preferences and prejudices.  An ‘optimal’ dose can only be judged by the person using it, even if we know ‘objectively’ its effects, whether in terms of intoxication or harm.  I might value my long-term health less than other people, and I might value intoxication more highly.  In which case 5g isn’t so much an ‘optimal’ dose as distinctly ‘sub-optimal’.

This is a strange position for a drug reformer to take.  The whole basis of David Nutt’s campaign against the current drug laws is that they have imposed some kind of moral, philosophical or political priority (intoxication is bad) rather than listening to ‘objective’ science.  But of course there is no universal, objective cost-benefit analysis of drugs, so the language around ‘optimal’ immediately raises the spectre of one set of personal judgements – those of ‘experts’, speaking as an oracle* – simply replacing another.

Previously, I’ve thought of this ‘rational’ approach to drug reform as simply naïve about not only policymaking, but the reality of social existence.

To summarise, the naivety about policymaking is first that telling politicians they’re behaving irrationally isn’t a great lobbying technique, and second imagining that ‘harm’ is the only thing drug policy could ever be about is misguided.  Not only can we not define ‘harm’ in any practical way that acts as a guide for policymakers, but there are plenty of other (legitimate) influences on policy other than reducing ‘harm’.  Balancing freedom, economy and morality is no mean feat.

And the naivety about social existence is simply that even if we’d like to start from some kind of ‘year zero’ in regards to drug policy, we’re dealing with substances that have a social history.  Whether we like it or not, the fact that alcohol has been legal and available in Britain for thousands of years makes a difference, when it’s compared with the substances that are currently illegal.

But looking at this again, I realise there’s something else that has troubled me about this approach, at a more emotional level.  I’ve been chatting about PSHE this week at work, and a couple of us were reminiscing about how, when we were at school, drugs education consisted of handing out booklets that contained key information on all the major drugs – where they tended to be available, how much they were likely to cost, what the effects were and how long these were likely to last.  Whether you ended up taking them or not, most people looked at that booklet and did a quick cost-benefit analysis to see which would be their preferred drug.  Perhaps not the intended response, but it illustrates a key point for drug policy: we didn’t all agree.

I think my problem, fundamentally, with the Delphi model is that someone else has done this cost-benefit analysis for me, and I don’t agree.  (Or perhaps more accurately, they’ve listed the costs, but not the pleasures that might balance them.)  What I’ve previously thought is naivety about policymaking or reality is, I think, arrogance.  A belief not that government making decisions about personal pleasures is wrong, but simply that they’re making the wrong decisions.

Back in the first few months I was writing this blog, I said that the most powerful and fundamental argument the alcohol industry could make in relation to alcohol policy would be based on liberalism, not on the technical details of research and modelling.  I understand why it might help to undermine or muddy the waters of ‘public health’ evidence, but that’s not really the fundamentals of this debate.

The same applies to drug policy reformers.  The debate is fundamentally about freedom: why should one person’s preferred drug (alcohol) be legal, while another’s (cannabis, or MDMA) is illegal?  Harm helps frame this debate, but it can’t drive it.  That’s not a question of naivety or pragmatism, but ethics.  Drug policy really can’t just be about science.

Friday, 3 January 2020

Thinking beyond a spectrum of alcohol use

It’s January, so I shouldn’t really be surprised there seem to be a lot of stories about alcohol in the press and online.  The particular one that’s caught my eye is this academic response to the ‘new sobriety’ movement, and an exchange on Twitter.

Alcohol Change UK could claim all this as a success, given that much of this is due to the prominence of ‘Dry January’.  (For those who aren’t aware, this is a voluntary commitment to give up alcohol for the month of January.)

Last year (as in most years) I wrote about some of my misgivings about the campaign - or rather, about how it’s interpreted.

Perhaps most obviously, we know that the people most in need of ‘behaviour change’ (and therefore support) tend not to undertake Dry January, and if they do then they’re less likely to complete it successfully.

One interpretation would be that this isn’t necessarily a bad thing: stopping completely in the way Dry January implies isn’t appropriate for some of the people most in need of support, if they’re physically dependent on alcohol.  And we shouldn’t be surprised that the people who have the most entrenched issues find it hardest to give up – that’s the definition of having a more serious problem.

What’s been on my mind this year is a slightly broader interpretation of this issue.  It’s not entirely new, but I think it’s worth highlighting. And as I do, I think it’s also worth mentioning that, unlike last year, I’m actually doing Dry January this year.*  This is absolutely not a post attacking the campaign.  The point is that I think anyone in the field should feel obliged to use this moment of media interest to raise wider questions around alcohol, rather than simply trumpeting the merits of ‘choosing’ to stop drinking for a month.

If you look at the evaluation of Dry January, it tells us what we’d expect for any similar behaviour-change programme: successful participants (defined as completing the month without consuming any alcohol) are most likely to be women, to have a university degree, and to be on a higher-than-average income.  They’re also more likely to report good physical health at the start of the month.

As I say, this isn’t really a surprise.  We know from other areas of public health that these characteristics make people more likely to find success in these kind of campaigns based around individual choice.  And that’s fine; it’s horses for courses – some approaches will work for some people and not others.

The danger is that those factors that make people more likely to find behaviour change approaches helpful are exactly those that mean they’re less at risk of harm in the first place.  Because harm from alcohol isn’t simply correlated with consumption.  (The ‘alcohol harm paradox’ shows that although it’s the richest in society who tend to drink the most, it’s the poorest who suffer the most health harm related to alcohol.)

This is where it gets interesting.  At the same time as there have been various pieces written about Dry January, I’ve seen a few things about ‘alcoholism’ and the idea of a spectrum.  In fact, they’re kind of prompted by each other.

Amy Dresner has expressed some frustration with the ‘new sobriety’ movement (which some would see Dry January as being linked with), because it underplays how difficult just ‘choosing’ not to drink can be for those with a more serious issue – which she labels as ‘alcoholism’.  I’ve written about this idea of alcoholism before,

James Morris has suggested that this perpetuates an unhelpful alcoholic/not alcoholic binary, when the reality is that people will be facing a range of issues across a whole spectrum.  Just because you don’t fit the classic definition of ‘alcoholic’, doesn’t mean you don’t have an issue with alcohol.

What I want to suggest here is that we need to see this spectrum as something more than a one-dimensional discussion of the severity of alcohol issues.  This has been proposed before, with people like David Nutt saying the best way to understand problematic substance use would be to abandon terms like ‘addiction’ or ‘alcoholism’ and simply look at ‘heavy use over time’.

Currently, though, when people think about problems with alcohol, these aren’t just about alcohol.  In diagnosing a ‘substance use disorder’ you might well look at consequences to someone’s home, relationship, work and so on.  In very few cases are these issues likely to be solely the result of substance use.  Things can enter a vicious circle, of course (substance use might intensify as other problems mount, as a form of escapism that only serves to make things worse).  But I mean something more than that: other issues may mean that the consequences of a particular level of alcohol use are worse for one person compared to another.

In a strange way, the reason there’s potentially tension between people who subscribe to a narrow definition of ‘alcoholism’ and those who advocate ‘new sobriety’ is that they share a lot of the same ground.  Alcohol is seen as absolutely crucial to both.

According to AA, the ‘alcoholic’ is a specific category of person who effectively has an ‘allergy’ to alcohol, and is best living without it entirely.  According to some of ‘new sobriety’ narratives, all the person had to do was remove alcohol from their life and they were suddenly able to wake up early with enthusiasm for their job (or with the passion and clarity of vision to start something completely new), and able to buy a house, and build better relationships with friends, family and lovers.

First, I should point out that both of these are caricatures.  In AA it’s widely accepted that the hard work starts once you’ve stopped drinking, and there are plenty of ‘new sobriety’ style advocates who would say the same.  And the reason the narratives are similar is because often we’re talking about people who have faced the same, serious issues.  As Amy Dresner points out, ‘If you CANNOT do a full month without drinking or if your life gets exponentially better when you stop drinking you might actually be an alcoholic’.  Chelsey Flood and Lucy Rocca are particularly good examples of people who could be seen to bridge the gap between these two camps.

But the point remains: in both narratives, alcohol is central and fundamental.  For ‘alcoholics’ there’s no life without removing alcohol, and for ‘new sobriety’ advocates’, just removing alcohol improves life immeasurably.

And this helps explain why Dry January works for some people.  Let’s go back to those successful Dry January participants.  They didn’t just tend to be healthy, highly educated, female and well-off.  They tended to believe they had a problem with alcohol, and this was confirmed through their AUDIT questionnaire (though of course this is dependent on self-reporting – we may each define problems and issues in different ways).

This makes sense psychologically and sociologically: we’re more likely to address a problem and persevere with solutions if (a) we genuinely believe it’s serious; and (b) we have some key resources behind us (‘recovery capital’ as they’re sometimes called) to support us.

In reality, for most of us who have issues in our lives and who drink what some people would see as ‘too much’, the precise role of alcohol is less clear.  Perhaps I’ll be proved wrong by the end of the month, but my previous experience suggests that I do not some hidden passion or clarity of vision that is simply waiting to be unleashed once alcohol is removed from my life.  And I can’t see that the things that make me angry or upset, for example, are going to be resolved by drinking less.

But it’s about more than that: it’s that for plenty of people you could remove the alcohol from their lives and things wouldn’t get demonstrably better.  Or it’s not just about removing alcohol to reduce their risk of health damage.  (Think of that alcohol harm paradox work.)

Therefore, if there’s an axis of ‘severity of alcohol use disorder’ that’s relevant to problems, there could also be another axis representing how much this is really about alcohol.

What does this mean for policy and advocacy though?

It means that anyone who’s serious about reducing ‘alcohol-related harm’ needs to think about more than just how many units people consume.  This is partly about patterns of consumption, but it’s also about wider social factors – exactly those things that make some Dry January participants more likely to succeed than others: wider health, employment, education, income, and so on.

This has clear implications for how we support people who do have issues with alcohol.  These can’t simply be addressed by appealing to individual choice, or by focusing on a person’s drinking.  There’s a need for services arranged around people’s actual lives as they live them.  (I’ve written about this before – for example here and here.)

There’s also a need for policies that address the wider structures that shape people’s choices and their lives – something that I’ve suggested in the past the sector has neglected, in its tendency to focus on a single initiative, whether that’s minimum unit pricing, alcohol labelling or Dry January.

So what does this mean for the value of Dry January?  It’s potentially helpful for a lot of people at an individual level, but for me its key contribution is about culture change, which then provides a space for policy change.

First, it prompts everyone to think about their alcohol consumption, and that fits perfectly with Alcohol Change UK’s admirable goal of getting everyone to make well-informed decisions.

Second, it provides an opportunity for commentators and policymakers to note that alcohol isn’t just any other commodity, and for all its strengths the individual-focused approach of Dry January doesn’t work for everyone, so we need more.

Anyone not making this case when talking about Dry January is, in my view, missing an opportunity, and even perpetuating health inequalities.

*Disclaimer: I did drink on 1st January, so I’ve started late.  Someone who had come to our New Year’s Eve party had brought a ‘polypin’ of about 9 pints of locally-brewed beer, and not all of it got drunk.  My Presbyterian heritage of ‘waste-not-want-not’ in this instance overrode the Presbyterian tradition of temperance, and I drank the remainder on New Year’s Day in front of the football on the TV.

Wednesday, 4 September 2019

From pleasure to vice to addiction

I’ve been reading quite a bit of fiction and non-fiction about substance use and ‘addiction’ lately, and some of the latest things have sparked me to wonder if we think carefully enough, or fundamentally enough about the issues.

I’m going to focus here on David Courtwright’s new book The Age of Addiction: How Bad Habits Became Big Business, but the points apply equally across a lot of the debate currently.  Although this reads a bit like a review, I’m trying to make a broader point that we’re sometimes not as clear as we could be about what the problem is and how we’re trying to solve it – and this is important if we’re going to develop effective public policy.

Courtwright’s book is a whistle-stop tour through the history of substance use, from prehistory and the development of agriculture through to the industrial revolution and more recent developments such as digital technology and online markets and interactions.  Although not mentioned in the title of the book, the argument hangs on a couple of key concepts.  He’s concerned with ‘vices’ and how something he calls ‘limbic capitalism’ has made us more vulnerable to developing these.

Courtwright argues that there are parallels in the ways we can get into trouble with different substances, whether we understand them as ‘drugs’ or not, and behaviours like sex and gambling.  What start off as being ‘pleasures’ can transform into ‘vices’ and eventually ‘addictions’.  In this way, the book is about sugary food and drink as well as gambling as much as more familiar issues grouped under the banner of ‘addiction’ like alcohol and other drugs.

Courtwright suggests that with industrial capitalism certain pleasures became more attractive and available, as urbanisation fostered psychological as well as geographical disruption.  For example, drink was more available in cities, you could indulge in pleasures with less fear of judgement as there are more anonymous spaces, and you had more reason to as there was less social connection and the work and living conditions were less stable and rewarding.  So the industrial age was one of vices, not mere pleasures.

But Courtwright’s warning is that we have moved beyond this form of capitalism and its associated vices to a new form – ‘limbic’ capitalism – and the issues emerging deserve the label of addiction, not just ‘vice’.  The word ‘limbic’ refers to the ‘limbic’ system, an idea Courtwright takes from the work of people like  Daniel Kahneman.  The idea is that humans have two ways of acting: through rational deliberation, making use of their ‘head’; and through more automatic mechanisms, often labelled as a ‘gut’ reaction.  It’s the ‘limbic’ system that’s responsible for the latter.  (Incidentally, I think Dan Gardner is more relevant in this context.)

Thinking about these two systems is one way of understanding the paradox at the heart of the concept of addiction: that we can knowingly act against our best interests.  When we employ our ‘head’ to think about things, we know a particular course of action is unwise, and we want to avoid it; but when, in the heat of the moment, we rely on our ‘gut’, we make a mistake – or a ‘lapse’.

Courtwright’s contention is that capitalism today is increasingly efficient at mobilising the ‘gut’ at the expense of the ‘head’, meaning that ‘addiction’ is more common.  Examples include the formulation and marketing of unhealthy food and drink and the design and delivery of computer games and social media through the internet and mobile devices.

The elegance of the this argument makes it attractive, though I would take issue with some of the claims.  I don’t want this to be a comprehensive book review, so I won’t go into detail here, but I worry that this view idealises the past and misrepresents the nature of addiction.

Prehistoric and agricultural societies were not innocent worlds where ‘pleasures’ never transformed into ‘vices’ – and although that isn’t what Courtwright is saying, there’s something about the argument that suggests there was some golden age where we had our ‘guts’ and ‘heads’ in balance.

Crucially, the ‘gut’ and ‘head’ are not entirely separate and we can’t quite explain ‘addictive’ behaviour in this way.  Representing two systems like this risks reproducing a Cartesian mind/body dualism, which has been critiqued to death.  While a Cognitive Behavioural Therapy (CBT) approach to issues around substance use might take the approach of getting people to actively reflect using reason, that isn’t quite the philosophy behind other approaches that many people rely on, including Alcoholics Anonymous (AA).  These approaches to recovery aren’t simply about prioritising the ‘head’ over the ‘gut’; they’re about re-training your ‘gut’.  Just as genetics and early experiences help determine what ‘pleasures’ we are most vulnerable too, so we can ‘re-train’ ourselves to form different tastes and habits.  The reflective can become automatic – so much so that the reformed smoker or meat-eater can find the smell of cigarettes or frying bacon viscerally disgusting.

But in a sense that’s by the by for Courtwright’s argument.  It could still be claimed that this is prioritising the ‘head’ in order to understand what is genuinely in our best interests, and then we can use the ‘head’ to slowly turn round the ‘gut’.  (I’m not quite convinced by this; encouragement to fake it till you make it and just keep attending meetings don’t feel exactly ‘rational’, or something the ‘head’ can entirely justify.)

But more important than these details are the issues of language and concepts.  Courtwright isn’t exactly clinical in defining what makes an erstwhile pleasure a ‘vice’ or ‘addiction’.  I suppose he would say that a vice is an indulgence in a perhaps fleeting pleasure where, at least in the long run, either you or someone else around you is harmed, and this can be understood as an ‘addiction’ where there is some sense of compulsion.

And perhaps this lack of clarity is forgivable in what is essentially a book outlining a grand narrative.  At some level my frustration with this is simply a matter of personal style and preference.  The sort of books and authors Courtwright is drawing on don’t do a lot for me – Kahneman, Steven Pinker, Yuval Noah Harari, Thaler and Sunstein and so on.  For me, too much gets lost in the grand sweep of the arguments, and they often include errors or oversights.

But it’s also a question about the purpose of these discussions (and these kinds of books).  Courtwright is writing because he’s concerned about trends in behaviour, and the economic and political forces that are moulding these.  The book ends for a call for us to avoid ‘excess’, both in enjoying pleasures and in our politics.  (I’m sure some members of the Drinking Studies Network would have plenty to say on this.)

Maybe it’s my personal baggage, but it all feels a bit ‘centrist dad’, like a cry for us to grow up and become ‘rational’ adults.  I felt like I was being told to drink less, go to bed earlier, and probably vote Lib Dem.

The thing is, that isn’t necessarily ‘rational’ for everyone.  One person’s pleasure is another’s vice.  The key question is how to define and police the boundaries between these categories of pleasure/vice/addiction.  Can we?  Should we?

If this is a call for a return to classical liberalism, we can’t be sure how we should regulate pleasure.  A reliance on single word like ‘excess’ cannot resolve the fundamental tensions in liberal thought, even if we could all agree to call ourselves ‘liberals’.  Think of TH Green and JS Mill arguing in the nineteenth century about what the truly liberal position on alcohol was.  When, where and how can lines be drawn defining competence, capacity, freedom and harm?  You might think I drink too much, but who can genuinely judge that apart from me?  What if I know the risks and I think what you might consider ‘excessive’ is actually perfectly balanced?

This might sound a bit abstract and overblown, but I want to illustrate that these are real, live and important issues for practice and policy at the moment.

First, let’s look at some of the things Courtwright seems to define as vices.  For example, he seems to worry about young people having no-strings-attached sex in the gap between high school and college (p.203), which, in itself, I can see little problem with.  The devil is, of course, in the detail of safety and consent – but that’s more complicated than condemning this kind of experience in itself.

Oddly he worries: ‘Me-not-them remains a popular game.  Try vaping instead of smoking.  Try cannabis for pain instead of opioids … Disney lobbied to keep casinos from competing for tourist dollars in its Florida backyard.  Yet it hired sommeliers to recommend wines in its restaurants’ (p.231).  None of these particularly worries me.  They sound like reasonable, pragmatic approaches that could well lead to more positive outcomes.  I’m not unquestioningly in favour, but I’d need a bit more persuasion from Courtwright to understand why each of them is a bad idea.

Courtwright even seems to suggest that banning e-cigarettes can be considered an ‘achievement’; a statement that itself would worry many public health professionals, let alone liberals.

Behind each of these statements are fundamental questions about what ‘the good life’ looks like.  Courtwright, for example, praises ‘mercantile and industrial capitalism’ for fostering ‘self-discipline, future orientation, and efficient time management’ (p.210) as if these are all unquestionable virtues.  As if they don’t exist on the same kind of spectrum as pleasure/vice/addiction.  Surely not all those writing during the industrial revolution would have agreed with the claim that ‘Innovation and competition, however fair and orderly, tend to make the social consequences of improved production worse, not better’ (p.226).

He therefore also seems to dodge the implicit question about the ethics of ‘nudging’ people into different behaviours, uncritically noting that certain environments ‘work for us instead of against us’ (p.228).  Who decides what’s ‘for’ us and what’s ‘against’?  How?

At root, we have a view that emphasises the value of rationality.  But there are two key problems with that.  First, there is no single definition of a ‘rational’ decision.  For example, Courtwright states that when Zadie Smith gave up Facebook to help her concentrate on writing a novel ‘She was wise to do so’ (p.209).  Perhaps, but how can we know?  And would we all be wise to do so?  There are plenty of people who have been inspired or supported by Facebook; even supported to give up their ‘addictions’.  How can we develop a general policy position on a medium like Facebook?

Second, constant rationality is not always productive – either for individuals or societies.  There is a reason that feasts and holidays were endorsed by rulers and ruled alike.

Is it that ‘vices’ hold real risks, or are they somehow imagined?  It seems to me that ‘self-control’ is valued not because the consequences of uncontrolled behaviour are risky, but simply because they are (in some people’s eyes at least) somehow irrational.  Well indeed, that is precisely the point.

Perhaps it could be argued that so long as not too much harm is involved, then activities could still be classed as ‘pleasures’ (or perhaps ‘vices’) rather than ‘addictions’.  And yet if they are not rational, how can they still be classified in this way?  How can we then draw appropriate lines between them?

If this still sounds like an abstract and indulgent academic argument, think of how we regulate e-cigarettes, the night-time economy or alcohol more broadly.  If vaping is somehow seen as a vice, not to be encouraged, this has serious implications for public health and smoking cessation  policy.

If we are not able to define clearer boundaries between ‘vice’ and ‘addiction’, then we will struggle to support people who have issues with heavy drinking.  As health professionals wrestle with the issue of why such a small percentage of people who drink heavily access support, there are plenty of people suggesting that we need a more nuanced approach to ideas of mental capacity and consent, arguing that, at a certain stage, we can define heavy drinkers as acting so irrationally against their best interests that they cannot sensibly be said to have mental capacity to make informed, rational decisions about their own welfare.

Without clearer thinking and writing, we won’t get closer to resolving these questions and developing policy solutions.  David Courtwright has offered an interesting and engaging contribution to the discussion, but for me he raised more questions than he answered.