Tuesday, 27 August 2013

Addiction, medicine and local public health

The Chief Medical Officer, Sally Davies, caused a bit of a stir a week or two ago.  On BBC Radio 3’s “Private Passions”, she acknowledged that she had taken cannabis a few times, in cookies.  This excited the Daily Mail, mostly for the apparent scandal of a senior public (health) figure admitting to having taken illegal drugs.  Ears also pricked up in the world of drug and alcohol policy, though, as Davies stated that addiction was a ‘medical’ condition.

I’m not sure I agree.  The term addiction isn’t clear.  For a start, you can distinguish it from physiological dependency, which can wane relatively quickly, while addition persists – that is, if you follow the EMCDDA in defining addiction as the “repeated powerful motivation to engage in an activity with no survival value, acquired through experience with that activity, despite the harm or risk of harm it causes”.  (On addiction, it’s worth listening to the beginning of this Radio 4 programme on addition, or reading this book.)

To an extent this is simply to acknowledge the psychological element of addiction, and that doesn’t in itself mean the phenomenon isn’t medical.  However, I’d argue that this idea that addiction is – or should be treated as – specifically or primarily medical is unhelpful.

We know that people’s health is affected (even determined) by factors that might not be thought of as directly medical: inequality, housing, social networks, the built environment.  And someone’s ability to overcome an addiction is affected by their ‘recovery capital’ – pretty much those exact same factors.

To suggest addiction is purely medical runs the risk of implying that, as a physiological problem, detox or a methadone script should resolve it.  This could detract from the attention that should be paid to secure housing, employment, social networks and all those other factors that influence how likely someone is to recover.

This is one of the reasons to be cheerful about substance misuse treatment now being housed in local authorities as part of public health structures: in theory, this should make it more likely that public health interests will be taken into account across different areas of local policy, from schooling, through transport and planning, to licensing.

In fact, it’s one of the reasons to think that public health is the right place for substance misuse as an agenda generally: public health should be about all these wider factors.

However, as I’ve suggested before, given the way we understand and regulate intoxicants in the UK, health issues aren’t the only ones that relate to substance misuse.  For example, Paul Hayes, former chief exec of the NTA, has noted the importance of the crime agenda in garnering support for drug treatment within government.

As with the definition of ‘addiction’, it isn’t always clear what is meant when people talk about drug-related crime.  Peter Ferentzy is probably right when he asserts that much violence described as ‘drug-related’ would be better described as ‘prohibition-related’, in the same way as we talk about Al Capone’s exploits.  And the Guardian editorial that commented on Davies’ point made a similar claim, but to hint at the advantages in decriminalisation or legalisation.

This is of course one of the underlying aims when people talk about treating addiction as a medical problem: the ‘addict’ shouldn’t by definition be a criminal.  But that’s different to Ferentzy’s argument, where he’s talking about violence/crime relating to the trade in drugs, not the taking of the drugs.  And being addicted to something isn’t a crime in Britain.  What’s criminal is possession of illegal drugs.  In fact, you can access physiological and psychological treatment for addiction on the NHS.  (I should actually say: via your local authority through a range of local or national providers, public, private or charities, but free at the point of use).

When we think of addiction as causing crime, we’re mostly thinking about shoplifting and so forth to fund a habit.  And that is drug-related.  It might be that legalisation could reduce crime – but only if people funded their use without committing crime.  One way that could happen is if legalisation made drugs cheaper*, but this would seem unlikely.

This is one of the reasons I’m cautious about drug treatment budgets being placed within public health: a key benefit of these services – and how these have been justified politically for more than a decade – is their role in reducing crime.**  Crime is only an indirect concern of public health, in that it reflects and reinforces a lack of social capital and security, which can affect health.  It is not included in the Public Health Outcomes Framework (PHOF)***, which is the primary structure according to which public health activities will be driven.

The other reason I’ve been cautious about the substance misuse agenda being housed within public health is that the public health perspective tends to think in terms of population-wide effects and activities.  MUP is (to some extent) a classic case of this, as James Morris has pointed out.  Although it can be presented as a targeted approach, one of its attractions is that although it would only have a marginal effect on each individual’s consumption, when that marginal reduction in risk is aggregated across the whole population, the effect on morbidity/mortality is significant.

There’s been debate in the drugs and alcohol treatment field – notably from Marcus Roberts of DrugScope – about how this perspective might affect treatment services.  The concern is that, actually, a very small proportion of the population are in need of treatment for, say, heroin addiction, and targeting an intervention on a small group is counter to this approach.  (There is anecdotal evidence there’s some grounds for this concern.)  The old NTA arguments, of course, are built around on this very point: that small population of heroin users accounts for up to half of all acquisitive crime.

I’ve been concerned about this, every time I hear discussions about drugs and alcohol drift to the problem of those thousands who are drinking above government guidelines, or the seemingly growing problem of drinking amongst older people.

This is partly a turf war: I think I have a natural tendency to want to defend the areas of work I’ve been involved with.

It is partly from this insular perspective that I’ve recently thought of a reason to be cheerful.  Unfortunately, it undermines the reason to be cheerful about public health moving to local authorities.

It seems to me that there aren’t actually that many population-wide policies that can be implemented at a local authority level.  The most striking population-wide policy – MUP – would require a national policy, despite the hopes of local directors of public health.  Local initiatives – such as this one in Bournemouth – have proved fleeting, and tend to be voluntary.
Or think of putting cigarettes behind screens.  It’s hard to imagine local authorities being able to persuade multi-national operators to introduce this only in one area.

Of course, there are areas where local public health could make a difference – in fact, all those I mentioned above: transport, planning, education…  The difference is that in those areas the aim isn’t to introduce (or spend money on) public health policies; it’s to influence existing policy or activity by adding a public health perspective.

It’s harder to think of population-wide projects that are simultaneously local that public health could spend its considerable budget on.  There could be universal education and information campaigns, but it’s not clear that these have significant effects.  Rather, local public health campaigns are likely to be targeted interventions – those proposals to address older people’s drinking would would be targeted rather than population-wide, for example.  In fact, local public health teams are quite used to targeting particular areas.  For better or worse (and mostly simply for convenience) public health initiatives often focus on ready-made communities – most often working through schools, but also by targeting particular geographical areas.

So my reason to be cheerful is that in fact drug treatment could be justified in these terms; it is the targeting of a specific ‘problem’ group.

What I’m hoping, though, is that Public Health keeps that wider view and manages to have that same influence on other departments and functions of local government.

*My understanding is that there is less acquisitive crime related to alcohol addiction because this is a cheaper habit.  Of course, the flip side of this is that there’s a considerable amount of alcohol-related violent crime related to drunkenness, separate from dependence/addiction, which we might assume would fall if alcohol was less affordable and therefore less was consumed
**Police and Crime Commissioners (PCCs) do have some money that historically went towards substance misuse treatment designed specifically for those with a criminal justice connection (the Drug Interventions Programme – DIP), but this was only a small proportion of the overall spend on these services, and in many cases is unlikely to continue to be put towards treatment.
***Violent crime rates are included in the PHOF.  However, these crimes, if they are related to intoxicants, tend to be linked with alcohol and/or ‘recreational’ drugs used in the night-time economy, rather than the crimes typically associated with addiction specifically.  I should also note that treatment outcomes for opiate users are included, but only defined in terms of the proportion of those in treatment who complete successfully in the past year..  This means that you could scale back the scale of drug treatment and still maintain (even improve) performance on this metric.

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