The pleasures of intoxication

My thinking on drugs and alcohol is often structured around the idea of pleasure.  I’ve written in the past about how this isn’t a terribly useful way to make sense of what we do around drugs and alcohol, as no behaviour – least of all drinking in the night-time economy – can be made sense of using such a black-and-white term.  But there is occasionally a use in having this kind of concept in the back of your mind.

As regular readers of this blog and/or my academic work probably know, I’m quite a fan of Pierre Bourdieu.  He basically argues that class is about something more than occupation, income or market position – it’s about how these attributes fit into society’s wider ‘symbolic economy’.  For the concept of class to be at all useful, it has to mean something more than any of these individually – it’s the thing that links all these and the other correlated attributes that mean we can identify someone’s ‘class’ by the clothes they wear, where they live, what car they drive and what they do for pleasure.

His work was concerned with how these different perceived groups are made, and what effect that has on our lives in terms of personal and political possibilities.  The groups are made by ‘distinction’ – features of taste that distinguish one person (and hence one group of people) from another.

Central to this mechanism of distinction is the idea that, for the bourgeoisie, form is separated from function.  For example, in relation to food Bourdieu suggests that while the working class eat food that is simple and high in calories – and eat it in a functional, unpretentious way – the bourgeoisie eats daintier food designed almost to hide the fact that the food is about taking on energy.

He builds his whole position as a ‘critique of the judgement of taste’, to suggest that the rules of ‘good taste’ always serve a social function of distinguishing people from one another, through hierarchies according to broader systems of value.

The relevance for alcohol studies is the stories people tell around their drinking – why their practices are pleasurable (and therefore valuable).  As James Nicholls notes, the pleasures of wine drinking are often quite divorced from one of the key defining features of wine: its alcohol content.  This can easily be analogous to Bourdieu’s discussion of food: some value drinks that get them drunk; others emphasise other, seemingly peripheral, features – that wouldn’t be obvious to those not in the know.

In a sense, this comes back to JS Mill’s ideas about happy pigs (or, actually, satisfied pigs).

“It is better to be a human being dissatisfied than a pig satisfied; better to be Socrates dissatisfied than a fool satisfied. And if the fool, or the pig, are a different opinion, it is because they only know their own side of the question.”  John Stuart Mill, Utilitarianism (1863)

By positing something greater than intoxication (or immediate sensory pleasure), the thinking wine drinkers place themselves on the side of Socrates in this statement.

But having read Bourdieu on the subject, how can a thinking drinker stand by this claim?  Any statement of ‘I like this drink’ to mean something more than ‘I like the taste’ can immediately be analysed to show that there is nothing fundamentally valuable in this practice other than the meanings we create for it.

(I don’t mean to advocate complete moral relativism – I am assuming that the happy pig isn’t hurting other people.  And I’m exaggerating when I write that there’s ‘nothing’ valuable in the practice.  Watching football, for example, might be said to have benefits in terms of social solidarity, getting people out of the house and so forth.  But that’s not why people experience pleasure in the practice – these positive knock-on effects aren’t what get people down to the County Ground on a cold, wet Saturday in November.)

In the face of such criticism, how can we continue to find pleasure?  As soon as we’ve thought through that our liking for ‘real ale’ is partly down to the perceived resonances with some fictionalised version of the past, surely that pint suddenly doesn’t taste so sweet (or rather, bitter)?  Saying (or thinking) these things out loud makes them seem a bit ridiculous, doesn’t it?

And in any case, you only like the taste of that drink because of the way you were introduced to food and drink, which is simply chance.

One response, of course, is to say ‘so what’?  Of course we’re products of our environment and like things that resonate with particular tastes, experiences and principles we’re familiar and comfortable with.

But that would reduce the distinctiveness of the practice.  The whole point of distinction is that ‘good taste’ is pure in the Kantian sense – it’s unsullied by function, and it shouldn’t be simply a product of our environment; it’s genuinely ‘better’ than other tastes, otherwise it’s nothing: there would be no hierarchy.

Again, you might ask, ‘so what’?  But my query now is: if this critical sociological/psychological approach was more widespread and took root in how people think, wouldn’t the ‘purest’ form of taste be the most immediate?  That is, the most genuinely ‘disinterested’ taste, that which would demonstrate one’s intellectual superiority by being able to critically analyse one’s own pleasures and place oneself outside of one’s position in social space, would be sensory pleasures.  Socrates would come over to the side of the happy pig.

This wouldn’t be such a new idea, given the ‘libertines’ of the 17^th and 18^th centuries or the status of drugs for intellectuals in the 1960s, but it does offer a way to have pleasure (and status?) for the sociologist or cultural theorist inclined to overthinking, and I can drink to that.

The concept of addiction

I've been thinking quite a lot recently about the nature of addiction.  This is prompted by an exchange on Twitter that mentioned 'functional alcoholism', and a presentation given by Mark Gilman at a recent conference hosted by the treatment provider CRI.

I'm certainly not the person to develop a new or more nuanced understanding of addiction, and this wouldn't be the place for me to do it.  But there is something I want to do here that I hope will be useful.  It's more of a general point about definitions and how we use concepts.  I wrote last week about how pleasure and happiness probably aren't very useful analytic concepts, even if they mean something useful to us in everyday conversation.

You could take an academic, intellectual perspective and suggest that concepts need clarity to ensure we have perfect, Habermasian communication.  I struggled to read and understand Habermas, but there's definitely a point something like this that should be made.

I've seen Mark Gilman talk a number of times now, and the central assumptions and conclusions of his presentations have been the same for the past two years at the very least.  One of his key contentions is that there are alcoholics or addicts as defined in the 'big book' of the fellowships.  And not simply that people who fit that characterisation exist, but they are the only people who are really addicted to substances; there might be others who drink too much for their health, but they're not addicts.  This particular group of people who are addicted are best treated using that 'big book'.

This seems perfectly reasonable, if it works.  That is, if AA or NA work for that category of people, we should absolutely be encouraging them to access these services.

I'm not going to question that evidence base here.  There's plenty of lively (and often uninformed) debate on that issue already.

But here's the rub.  When we talk about 'addiction', what do we mean?  Some people would argue that the term is so disputed and inexact that we should cease using it entirely.

But Mark Gilman would argue that he's doing the opposite of this: he's using it precisely, with a very narrow but clear definition - taken from the 'big book'.  And for these people, the idea of 'controlled drinking' could be hugely destructive.  This is certainly a different perspective from the New Directions conference I attended this summer where there was something of a retrospective on 'controlled drinking', and researchers like Marc Lewis expressed their admiration for this stream of work.

And here's where my sociological, methodological objection comes in.  I don't subscribe to some Platonic model whereby concepts pre-exist human thought and signify some kind of absolute reality (that we may or may not grasp) and we're on a process of working out what addiction 'really' is.

Instead, I'd argue that any such concept isn't god-given, but only exists as a human construct, and is only useful insofar as it helps us to understand the world around us.

And so the authors of the study I link to above are right: if 'heavy use' gets us further to understanding what's going on and how to address it, then let's stop using the term addiction as a technical, clinical term.  I happen to disagree, but at least the debate is taking place on the right terms.

By this understanding, there's no problem with the Mark Gilman approach or the 'big book' definition of addiction, but equally it's important to note that if this is 'addiction', then there's also lots of people who have something more problematic than simply drinking at a level that is harmful to their physical health who don't then 'recover' from their issues in the way suggested.

There's a further problem too: the reflexivity or self-awareness of human beings.  Concepts about human behaviour don't simply exist in a vacuum; they also reflect back and shape that behaviour.

Think of economics.  Lots of critical theories of neo-liberalism note that economics and its metaphors haven't simply described the world of human interaction; they have also shaped that behaviour by making people think not only that they do behave like 'economic man', but that they should.  We internalise the tenets of neoliberalism.

This argument is closely linked to certain claims regarding the influence of psychology - as well as trying to describe and explain our behaviour, these theories or worldviews change it.

You might not agree with the arguments in these particular examples, but there's no doubt that if you get a diagnosis of your behaviour - which is inevitably determined by a mix of structure and agency, individual choice and wider determinants - this diagnosis (knowing what you are 'like') will affect those conscious elements of behaviour.  In fact, that's one of the reasons the AA model of addiction is opposed by people like Stanton Peele: it deprives people of their agency at precisely the time when they need to be toldthey can change long-term patterns of behaviour.

I'd suggest that both those suggesting 'heavy use' as an alternative to 'addiction', and those sticking resolutely to either a DSM or 'big book' definition are playing a strange game of trying to pin down the myriad of complex ways people can experience problems in relation to a range of substances (or behaviours) into one unifying theory.  Perhaps such a debate clarifies what is actually problematic about certain forms of substance use, and how we might address this, but it also risks obscuring 'different' issues or patterns of behaviour.

And these definitions aren't simply academic.  Mark Gilman is proposing service design on the basis of segmenting the potential users of services by these categories, and DSM definitions will affect what sort of treatment people receive - or even if they receive any at all.  That means the 'accuracy' - or perhaps inclusivity - of these definitions is crucial tothe chances of recovering that individuals might have.

So by all means let's have a debate about what 'addiction' or 'dependence' or 'problem substance use' might be, but let's do this with an awareness that you can't capture such issues perfectly.  And such concepts, even if they're continually developing, aren't moving towards a more and more refined and correct definition.  Moreover, they need to be continually developed, as they're linked into a feedback loop as they impact on the very behaviour they're trying to describe.

At best, these concepts might become more useful as they develop.  My fear is that today these debates mean they're becoming ever less useful, as people in the field talk across each other and exclude certain people and understandings.

Drinking and happiness

I've been thinking quite a bit recently about happiness and drinking.  This was prompted by a call for papers on leisure and happiness I was interested in.  Initially I thought I could flog the dead horse of the carnivalesque again, thinking of drinking - or at least the night-time economy - as a form of leisure, but mulling it over I've started to wonder whether there's anything we can usefully say about drinking and happiness at all.

I've written before about drinking and pleasure, and how I can't see that the concept of 'pleasure' is much use analytically at all.  From some perspectives, notably economics, if we do something we must by definition find it pleasurable at some level.  On the other hand, if we start to try to develop the concept into something a bit more nuanced, then it falls apart.  Is anything we do solely about 'pleasure'?

I remember at school being asked a question as part of an introduction to philosophy pleasure: would you commit to spend the rest of your life in a pleasure machine?  Of course, plenty of philosophers would say no, as this wouldn't amount to 'fulfilment' (or Aristotle's 'eudaimonia'), but I've never quite been convinced it isn't better to be the utilitarian 'happy pig' than an unhappy philosopher.  It was suggested to me at school that it wouldn't be pleasurable to be connected to such a machine, as you need the lows to appreciate the highs.  But my response was (and would still be) that if that's the case, the pleasure machine is flawed.  Those lows are not pleasurable in themselves.

So immediately we have this idea that true pleasure or happiness comes from there also being 'lows' or unhappiness.  And in practice that's the case not just with opposing leisure (pleasure) to work (unhappiness and/or fulfilment) - and there's plenty of academic work on this.  In fact, almost any action, or leisure activity, is imbued with something more complex than happiness or pleasure.

If we think of drinking, the whole reason I've employed the concept of the carnivalesque is that people aren't completely happy and comfortable just feeling pleasure on their nights out.  Part of the thrill and excitement is the discomfort, uncertainty, risk and so forth.  And the feeling of drunkenness is certainly something more than simply happiness or pleasure.  There might be a stage of drunkenness people describe as being pleasurable, but it's only one element of drinking, and not many would equate it with being (necessarily) happy.

At first sight, drug use is the ideal example of something that might approximate a 'pleasure' machine - the substances supposedly stimulate our nervous system to give us chemically-induced pleasure.  But it's all a bit more complicated than that.  There aren't many drug users who would simply talk in terms of pharmacological pleasure - and as a recent posting on Points reminded me, we do actually have to learn how to find certain experiences positive rather than disconcerting and unpleasant.

But perhaps once we've done that learning, drug use might make us 'happy'.  However, I'd suggest that people's 'happiness' isn't directly related to their substance use, and they wouldn't discuss it in those terms.

And it's not just about nights out.  In leisure studies there's an idea of 'serious' leisure, where the activity as seen as requiring practice, expertise, knowledge and so forth.  It is a form of working on one's body and/or life.  Such a model of leisure might make sense of some approaches to wine or craft beer - there is a canon of knowledge the expert needs, this isn't about pleasure or even happiness quite, and there is work and distance from pleasure required to 'achieve' connoisseurship.  In fact, it's not so different to the learning and expertise required if you take the approach of Drug, Set, Setting.

Of course, one way round this analytically is to say that true 'happiness' or 'pleasure' is closer to Aristotle's eudaimonia, or fulfilment - but that's basically saying these concepts as we actually understand them are redundant.  'I was happy in the haze of a drunken hour but heaven knows I'm miserable now' only works if these are neat binary positive/negative concepts - and in this context (and most others) what it really means is momentary pleasure.  That's not eudaimonia.

Most of the time, we don't live our lives in those black and white terms - or maybe that's just me.  Certainly it's very hard to look at a particular drinking practice and say that it leads to happiness.  But maybe, again, that's just me.

Unless, of course, you're watching a drinks advert.  Certainly those images familiar from brands such as Thatchers tempt us to see drinking with friends as being a moment of happiness.

But I'm not sure that works in quite the same way for the actual drinking we experience.  I think any discussion of drinking in terms of happiness misses the point - but in exactly the same way as it would for any other aspect of our lives.  Watching Swindon Town doesn't (very often) make me 'happy' - but that's not really why I do it.  I'm not sure listening to music makes me 'happy', though some specific songs might do.  And should we be aiming for happiness in any case?  That's a question for philosophers and sociologists like Will Davies to answer.

Alcohol Concern and evidence

When I started this blog, it tended to feature swift responses to things that had been in the news that day.  These days, whether because I'm busier or lazier, I tend to be a bit slower off the mark.

A few weeks ago, Alcohol Concern published a report about trends in drinking patterns across Britain.  I found this report pretty weak and frustrating, but limited my response to a few self-indulgent tweets.  However, since then, the report has been picked up by Russell Webster, who has praised it, and so I feel that I should put down my concerns in full a bit more clearly.

First of all, I have some concerns about the sponsorship of the report.  As regular readers of this blog will know, I'm not particularly opposed to industry influence on policy, so long as that influence is clearly stated.  And influence of this kind isn't always straightforward.  I'd suggest that when tobacco companies fund the IEA, they aren't directly shaping the outputs of that organisation as much as they're making sure that a free market position has a powerful voice.  It's the same when SABMiller sponsors Demos - they know that their work is structured around ideas of 'parenting' and 'character', which suits them well, so they want to support that voice.

And so we can see the sponsorship of Alcohol Concern by Lundbeck in much the same way.  Both organisations have an interest in particular drinking patterns that are currently accepted as relatively 'normal' being labelled as problematic - Alcohol Concern because they are firm in their belief that there is no 'safe' level of alcohol consumption, and Lundbeck because they are - or were - trying to market a drug to treat a level of consumption that historically hasn't been seen as requiring any formal intervention, let alone prescribing.

So in a sense it's no surprise that one of the 'key findings' of the report was 'people who want to quit or cut down might benefit from treatments like patches or pills'.  Luundbeck, as you're probably aware, make Selincro/Nalmefene, which has within the past year been approved by NICE as a treatment for people who drink at high-risk levels but who aren't dependent.

Of course there are prescribing interventions that are useful in some cases where people want to cut down or stop drinking, but it seems odd that in a big picture style report this was seen as a major concern.  Access to medication isn't something most people in the field I speak to are too worried about.  In fact, this comes just at the point where in other comparable areas of public health - drugs and tobacco - we're seeing a possible move away from medicalised or prescribing interventions, in favour of talking therapies, peer support and innovative developments like e-cigs.

My other major concern with the findings of the report was the way it looked at alcohol consumption in isolation from other factors.

Having had a discussion along these lines with Jackie Ballard at the launch of a report on older people's drinking, I feel confident that I know why this is, and it's for the same reason that lies behind the sponsorship arrangement.  Alcohol consumption is viewed by Alcohol Concern as a problem in itself. 

I challenged Jackie on this point, suggesting that she was misrepresenting the nature of risk - we know that plenty of people consume at 'high risk' levels without suffering the levels of harm associated with this on average.  I didn't get anything like a satisfactory response, with Jackie simply stating that of course any amount of alcohol is harmful - even as we'd just been told that some of the people with the greatest longevity in the study had been drinking at high risk levels.

(And that raises another methodological issue with the report: using a chief executive as a specialist expert in the field to deliver findings such as 'There is possibly a view that wine isn’t dangerous; - I thought that was the sort of finding a study like this was meant to investigate, rather than leave it to armchair pundits to ponder what people might 'possibly' think.)

My particular concern in the context of the older people's drinking report was that the issue we were grappling with was how to communicate the dangers of drinking to people who can't see any ill effects of their habit.  We face the same problem with new psychoactive substances: if we go around saying that these substances kill people, it just won't sound credible to the people actually using them, who may have examples of 1,000s of instances of use without any serious harm.

And part of the problem with alcohol consumption and harm is the 'alcohol harm paradox', which suggests that although people from the highest income and wealth brackets drink the most, they also suffer the least alcohol-related harm. Although there's all sorts of issues with the data that go into these models (for example about the relevance of 'special occasion' drinking), one of the important points is that other factors exacerbate people's risk of ill health: it's not just a matter of controlling for various independent factors, as they interact and amplify each other's effects.

So when Alcohol Concern state as a key finding that 'heavy drinkers tend to be well educated' and 'people who drink care about keeping fit', they're in danger of directing our attention in the wrong direction.  It's particularly strange that they do this while noting in the very same section: “health inequalities in society also mean that alcohol has a relatively greater impact on people in lower socioeconomic groups than their higher earning counterparts”.

Of course, there's always politics about these discussions of what drinking is problematic.  The danger in being too vocal about how alcohol-related harm is most concentrated amongst lower socio-economic groups is that it reinforces that old view that working-class drinking is the most problematic, rather than domestic, middle-class wine drinking.

However, on the flip side, I have a huge fear that in a time of astonishing cuts to the budgets available for substance misuse treatment, we don't need attention being drawn to well-educated drinkers, when they don't experience the highest level of harm.

But then, that's because Alcohol Concern see a direct, unproblematic link between levels of consumption and harm.

For me, by contrast, we should start with the harm and address that, and if we need to use consumption as a proxy for harm, that's fine, but we need a lot more other data and it can only be a proxy.  So in fact this is more than a political point, it actually gets to the heart of what we're defining as being problematic about alcohol.  If it had no health effects, I think we'd be hard pressed to identify a definite problem with domestic consumption of alcohol, even if it led to intoxication (setting aside risks of setting your house on fire by cooking when drunk).

But the question of what’s problematic about alcohol consumption is a bigger discussion for a different day.

A post-carnival drinking world?

I’ve just recently had an academic article published that tries to go beyond my previous work on the carnivalesque to argue that this is a useful concept not only to make sense of drinkers’ behaviour, or the government’s understanding of ‘problem’ drinking, but also producers’ approach to trying to sell the idea of drinking in a particular way.

The only thing is – and I don’t want to turn this into a classic academic moan about the delay in getting academic articles published* – that I wonder whether this neat argument now holds.  Of course you should all head to the website and read the paper (or email me for a copy), but this idea that we were all excited by (and/or concerned by) carnivalesque drinking possibly held true in 2008-09, when these ideas were first running round my head.  It’s not so clear that it’s accurate in 2015.

In the past year or so, I’ve been thinking about the parallels with 100 years ago.  Why aren’t certain policies seriously considered – notably the sort of control introduced by the CCB during World War One?  I had been thinking about this in terms of neoliberalism, but then books by Rob Duncan and Henry Yeomans have prompted further thoughts of this kind.

I gave a seminar presentation trying to draw out parallels between the policy and pub positions of now and 100 years ago, and I think it’s worth noting that in both periods, policymakers have been concerned by vertical drinking, people drinking without food and determined drunkenness.  Parallels can certainly be drawn between the ‘improved pubs’ of the interwar period and the Wetherspoons and similar today – indeed David Gutzke has done precisely this in his latest book.

In a nutshell, whether you’re reading Gutzke, Yeomans or Duncan, the parallels are immediately apparent: what’s defined as ‘respectable’ drinking for both policymakers and brewers/pubcos looks much the same in 2015 as 1915, and isn’t defined by quantity consumed as much as controlled (middle-class) domesticity.  For all that today’s public health campaigners are concerned by the quantities of alcohol that people consume at home, domestic drinking continues to struggle to enter the policy debate as a key issue, except where it amounts to ‘pre-loading’.

True, one can be a little more sceptical of pubco motives (and I am).  The same company will operate one bar that embodies the ideals of ‘respectable’ drinking, and another that takes advantage of the cultural capital and respectability it has earned.

The sign outside the Mitchells & Butler's venue in Bournemouth 60 Million Postcards

 

Picture from the website of the Mitchells & Butler's venue in Bournemouth Brasshouse

Despite this, though, we do seem to be genuinely beyond a period in which expansion and the explicit promotion of the carnivalesque is deemed acceptable or desirable for venues and alcohol producers.  It just doesn’t seem to be a wise business strategy.  This may owe something to the youth market being more ‘sober’ than to some idea of public acceptability, but nevertheless it suggests a different public policy environment.

I don’t know of a comprehensive analysis of the shift in motifs and approaches of alcohol advertising over the past 20 years, but there must be something out there.  Certainly there’s a difference between the Bacardi cat, Smirnoff nightlife and WKD, when compared with more recent campaigns by Thatchers or Strongbow (or maybe this even more recent one).  The first three suggest clubbing and the carnivalesque, playing with accepted roles and normal vision.  The latter ones are more about a legitimate reward for a job well done: time with friends and family.

But perhaps this says more about the differences in marketing for spirits and RTDs compared to cider and wine?  I don’t know, but it’s at least worth thinking about: are we living in a post-carnival world?  And even if the newer Bacardi strapline is ‘untameable’, which sounds pretty Dionysian, the feel is quite different from that cat or Vinnie Jones a decade ago.

I’ve written before about how alcohol needn’t always be a big political issue, and how there needn’t be an adversarial relationship between industry and public health campaigners.  This was what happened after WW1: alcohol wasn’t a significant political issue and that was partly down to the industry continuing to operate while the broad aspirations of campaigners were met.  The carnivalesque is a concept that makes sense of the somewhat adversarial policy debate.  Perhaps, with falling rates of consumption today, ‘binge’ drinking possibly going out of fashion, and an industry that seems more interested in selling domesticity and friendship, the carnivalesque is yesterday’s news.

*Though this one did take over 18 months from first submission, and quite possibly won’t be in print for another year.

Educating local policymakers in the art of making policy

I’ve recently had an article published where I suggest that recent changes in the supply of intoxicating substances and treatment for their misuse mean that local decisions are more important than there were in the New Labour years, when policy in the field was pretty strongly centrally controlled.  Now, where we had the NTA setting very clear requirements for local treatment systems, public health and local authority officials have a fair amount of autonomy about what they commission, and the local supply of alcohol and particularly new psychoactive substances is heavily dependent on operational decisions by police, licensing and trading standards.

As a result of this claim, I have suggested that some locally-based policy research would be useful.  That is, while we have pretty good stuff on national policymaking through the likes of James Nicholls, Vital Katikireddi and Paul Cairney, we’re less strong on how similar processes operate at a local level.

I’m not talking about how ‘street level bureaucrats’ like frontline treatment staff or job centre employees turn national policy into reality.  What I’m interested is that you could actually have a situation where rather than the government defining what the priorities and aims for drug treatment are (reducing acquisitive crime and HIV and Hepatitis transmission), these are set by local politicians and officials, and vary from one county to the next.  Maybe Cornwall decides it’s concerned about ‘binge’ drinking while Devon thinks it’s all about ‘legal highs’ and steroid use.

There might be nothing wrong with that, but it seems unlikely that the decision will have been taken on anything like a scientific ‘evidence-based’ rationale – and in fact it’s not possible to set prioirities simply on the basis of evidence.  You could get some analysis that shows the relative costs and benefits of different priorities and interventions, but you wouldn’t be able to action them all, and so the decision about which to invest in will be necessarily political, or subjective.  (I know, this isn’t a new point for me to make.)

So what I’m interested in is how these decisions are taken.

There was also, not so long ago, a call put out for applications to the NIHR for researchers to engage in ‘knowledge mobilisation’ activities.  This project aims to get research findings out to the coal face to make a difference to practice.  For example, there’s a pilot trying to make commissioners of care more aware of research, which will then be evaluated to find out what ‘works’ in making their decisions more research (or evidence) based.

And, (without forcing it to happen just so I had something to blog about) I started to wonder whether these two things could be linked.

I started to wonder: doesn’t policy research have implications for policymakers too?  I’m not just interested in finding out how people make those increasingly important local decisions I was talking about; I want to know if we can improve the policymaking process.

This isn’t just about making it more closely approximate some idealised technocratic evidence-based process.  I don’t think policy can ever be anything other than political, and there’s nothing wrong with that.  In fact, we should embrace it.

National policymakers are well aware of this, and academics producing research are perhaps catching on too – there are certainly enough people writing about this and the way ‘knowledge exchange’ should happen.

But in attending various conferences over the past few years, and particularly since my job moved over to a public health department earlier this year, I wonder whether this has translated to all (local) policymakers, given those changes outlined in my article, whereby there’s something of a double whammy for the sphere of substance misuse: there’s increased local autonomy that means people who were previously technocrats are more like policymakers; and at the same time that autonomy comes with increasing political oversight, as funds have been consolidated into local authority budgets when they used to sit within the NHS, with its very different ‘commissioning’ and budgeting processes.

So if there’s an opportunity for knowledge mobilisation in this area, I’d say it wasn’t to increase commissioners’ awareness of the evidence base for treatment or prevention, so much as to sensitise people who have now become local policymakers to the latest research on the policymaking process, so this can be as good as possible.  As I wrote in a previous post, I don’t think public health officials do themselves any favours when they ignore the political nature of policymaking and imagine it is simply about listening to the evidence and taking either a ‘good’ or ‘bad’ decision.

Now that would be an interesting bid for NIHR funding: educating new local policymakers in the art of policymaking.

On the politics of compromise

I don’t often write directly about party politics on this blog, because mostly I’m talking more about the process of policymaking than its moral positions.  And perhaps that’s true of this post too, but it is written in direct response to the way the Labour leadership debate has been conducted.  It’s not a direct commentary on particular candidates or other public figures, and it could be seen as a call for all of them to up their game.

I’ve often said on this blog that policymaking is about compromise, and the same must be true of politics more generally – for even when it seems that nothing’s being done, that’s a policy in itself.

But compromise, particularly at the moment, seems to be a dirty word – or at least one that’s probably misleading for what I want to try to say.  Really, the point is that all policies are (even if not consciously) a weighing up of inevitably competing positions and priorities.  There will be trade-offs.

Some of these trade-offs might involve cost (how much can we spend on crash barriers, medicines, school buildings, or how much do we want to prioritise the environment over economic growth), but for others it’s simply about balancing one legitimate priority against (many) others.  To take an example from a field I know something about, how can prescribing methadone to reduce the harm from injecting illicit drugs be balanced against the desire to support people to ‘recover’ as fully as possible from substance use issues?

What I’m trying to say is that by talking about ‘trade offs’ I don’t mean that Jeremy Corbyn’s policies – or those of Kendall, Cooper or Burnham for that matter – are ‘unrealistic’, as some Labour grandees seem to want to do.  I just want to point out that they will involve a trade off with some other potential priority, whether that’s conscious and spelled out or not.  Of course that potential priority might be written off as unimportant, but that’s easier for a big picture discussion of growth versus climate change than it is for the detail of adult social care policy, for example.

But there’s a bigger point about compromise and politics.  I see it as inevitable that not all people agree on the ends of politics, let alone the means.  Otherwise, we might have found a unifying political theory by now, but not even liberalism has managed that with its attempt to bypass any attempt at unity.

So no policy will please everyone.  Of course some views would disregard popularity, but some concept of popular appeal is important if you’re interested in power, which is the only reason a person is interested in politics (even if they, quite reasonably, think power doesn’t entirely reside in government).  It’s revealing that the campaign teams of both Andy Burnham and Jeremy Corbyn have been desperate to point out that their candidate has widespread popularity and electability.  Despite what some Labourites might think, the Corbyn campaign isn’t simply an attempt to sit aside from the mainstream of political debate and feel self-righteous.

And here’s my point: the Labour Party is itself, inevitably, a compromise.  It is an electoral coalition for the purpose of forming governments.  This isn’t its only function, but it’s the key reason it exists as a political party as separate from – or alongside – ‘the labour movement’.  The Conservative Party is a compromise too, for that matter.

Just as we haven’t got one unifying political theory we can all agree on, neither have the major parties.  They can’t be neatly categorised according to the classic axes of political theory.

Alcohol and drug policy is one area where we can see this clearly.  The Labour Party can’t decide whether minimum unit pricing of alcohol (MUP) is a progressive measure that will reduce alcohol-related harm amongst the most vulnerable, or whether it’s a way of targeting some people’s pleasures while leaving richer people’s untouched.

And the Conservative Party can’t decide whether liberalising alcohol licensing or drug laws is the right thing to do because it’s economically and socially liberal, or whether intoxication and visible carnivalesque behaviour are undesirable and therefore should be cracked down on as part of a socially conservative agenda.

These aren’t new problems.  James Nicholls has written very clearly about how the politics of alcohol highlights these liberal dilemmas, and the issue of alcohol for Labour Party politicians was laid out clearly in The Ragged Trousered Philanthropists over 100 years ago.

And yet, so far, these parties have tended to hold together.  Yes, there has been the SDP, and Douglas Carswell has chosen to see UKIP as a genuine libertarian alternative to the Conservatives (though I’m sure plenty of UKIP voters and party members would disagree).

Politics involves trade offs at some stage.  Our political and electoral system tends to place these at specific stages, but they’re still there.  In some other countries the compromise is made after an election, when a programme for government is put together by several parties accepting portions of each other’s manifestos.  We had our own experience of this after the 2010 election, and it didn’t end well for one of the compromisers.

(You could argue that 2015, with the exception of Scotland – or perhaps particularly in Scotland – was a turn back to clear two party government, rather than an endorsement of coalition or a further fracturing of political loyalties.)

The British electorate largely know they are voting for a compromise rather than their perfect party – but (under current electoral arrangements) they prefer to know what compromise they’re likely to get before they vote.  The compromise is effectively put to them as the programme of the two biggest parties, which are already ‘coalitions’.

There are other ways to conduct politics, of course.  We could vote for our ‘perfect’ party and spell out our compromise option through an alternative vote system.  We could have many parties with more coherent and tightly defined programmes for government, and then see negotiations set in after the election.

But I would suggest that parties, as a collection of people, and the expression of a collective will, cannot be wholly of one mind.  Those compromise manifestos not only cannot satisfy every voter, or even just the voters of that party; they cannot fully satisfy anyone.  Its policies will be a series of trade-offs, and the selection of policies will be a compromise rather than a perfect, complete vision of one mind.  That is the nature of living with other people.  (Unless, of course, you’ve found you’re living in a society where you never disagree with anybody – that would be interesting to know about, but it certainly wouldn’t be interesting to live in, or even human.)

Even smaller, ‘purer’ parties can’t achieve perfect agreement on a programme for government.  (I would argue that even an individual human being isn’t capable of that level of coherence and consistency, but that’s an argument for another day.)

So let’s not have one politician written off as a compromise candidate or another as an unrealistic idealist.  Compromise does not inevitably mean Tony Blair or David Cameron, any more than purity of principle and thought means Jeremy Corbyn.  There are compromises other than those made by the 1994-2010 Labour Party – but they will be compromises.  The trade-offs are made by everyone, or will be later.  The question is about the relative priority given to certain principles or priorities.

To paint compromise – as particular Labour members of all backgrounds and preferences have done during this campaign – as being one specific thing, infantilises political debate.  Reasoned, balanced, publicly-supported policies are not a bad thing – and they could come from any of these candidates or none.

Not a single candidate is ‘perfect’, but then there never will be a single ‘perfect’ candidate or policy platform for everyone, so let’s stop pretending this is a battle for head or heart, realism or perfection, and get on with some proper discussion.  Blairites don’t have a monopoly on realism, and Corbynites don’t have a monopoly on leftwing morality.  My ideals, my compromise, my realism are quite different from anything I’ve seen so far.

It seems a travesty to argue that what we could call consensus politics should be defined by Tony Blair, when the period called by that name is precisely what he was most keen to distance himself from.

Now what are the candidates’ positions on minimum unit pricing anyway?  That might actually be illuminating about their principles and priorities…

Drugs, harm and sceptical conservatism

I do occasionally stop thinking about the concept of evidence-based policy, but at the moment I seem to keep coming back to it.

With a certain arrogance, my aim in setting up this blog was to contribute to an open and honest debate on various policy issues, but particularly those relating to drugs and alcohol.

Regular readers will know that I don’t have much time for the idea that there is a single unquestionably ‘right’ answer to any policy problem, as every decision is necessarily a compromise.  I’m more interested in ensuring that when we’re making those compromises we’re going into them with our eyes open.

On the walk to work last Friday morning I was thinking about NPSs (novel psychoactive substances or ‘legal highs’) and nudging – and, oddly, but not unusually, sceptical conservatism.

My thought was that both nudging and this form of conservatism are based on a view of the world as being irrational, but functional.  It’s just that where sceptical conservatism thinks our ostensibly ‘irrational’ society has huge strengths, nudgers want to change our actions to make them more ‘rational’.

But what’s that got to do with NPS?

Well, I don’t think there’s any serious argument that our overarching policy approach to intoxicating substances is ‘rational’ – though perhaps that would be an oxymoron in any case.  Certainly there’s an inconsistency laid bare by the new Psychoactive Substances Bill in relation to caffeine, alcohol, nicotine and certain other substances.

As I’ve written before, I was optimistic that NPS and e-cigs might disrupt the status quo and get people to question current arrangements.  Others were more sceptical – and possibly more accurate.

But here’s the link between conservatism and nudging.  There are serious ethical debates around nudging, based on the fact that it operates on your unconscious ‘thinking’ – System 1.  But we are able to override this system (to some extent) with conscious thought (System 2).

So what if a ‘nudge’ lost (some of) its effectiveness if its aims and methods were broadcast?

That is, what if you told everyone that you were placing the doughnuts in a particular location in the café in order to reduce their consumption – and telling people this meant they didn’t react to that move?  The whole approach potentially depends on us being in blissful ignorance.

And it’s the same with sceptical conservatism.  Society is too complex for us to understand, and it works reasonably well.  We shouldn’t think too hard about how it’s working and try to tweak things to make them more rational – that way lie the horrors of the French Revolution.

But then what’s all this irrationality and unconscious stuff got to do with NPS?

Well, as I said before, there’s a view that our drug policy isn’t strictly ‘rational’, but it isn’t disastrous, and a complete revamp would be hugely risky.  Alcohol and tobacco might not be so different from banned substances in terms of their pharmacology, but their unique histories mean they’re understood quite differently, so it could be argued that the ‘irrationality’ is perfectly ‘rational’ given the irrational place we find ourselves in.

I’d suggest that the Psychoactive Substances Bill is an attempt to support the status quo, and there’s no mention of ‘harm’ because to frame the debate in this way would highlight the inconsistency of this current approach.

So this is where sceptical conservatism, nudging and drug policy interact: we don’t talk about the irrationality of policy for fear that would destroy the illusion – and if we thought too carefully about alcohol and drugs, maybe the (arguably) functional arrangement we currently have would fall apart.

So is it possible that one way to keep harm from drugs down is to not talk about harm?  And is that a policy compromise worth making?

Yes, it's politely political

I’ve been thinking and talking about evidence-based policy a lot lately.  Conversations at work with Public Health colleagues; the conference of the New Directions in the Study of Alcohol Group (NDSAG); various blogs and Twitter discussions.

After the NDSAG conference, I flippantly reduced much of the content to be being the sentiments of this song:

But it’s actually more than being flippant.  At the conference, which focused on the nature of addiction and pathological behaviour from alcohol use through other drugs to behavioural addictions such as gambling, many of the debates boiled down to the old political and sociological chestnuts of structure/agency; pleasure/harm; individual/society; freedom/safety.

As Jim Orford powerfully argued, at root these come down to issues of power, but I was reminded of my basic undergraduate paper on political sociology when the likes of Steven Lukes were being quoted.  Really, power, like addiction, is just another word or concept (and really a set of concepts) through which to think about all these problems.  In itself, a conceptual lens doesn’t resolve a problem; it provides a way to think about it.  (With the exception, of course, of the concept of the carnivalesque, which resolves all our issues with alcohol policy – of which more in a week or so.)

What thinking of these issues in terms of power reveals, though, is the seriousness of Skunk Anansie’s point.  (I don’t know if this is a better or worse use of musical analogy than Billy Joel.)  Issues of power are political, and when we talk about addiction, or indeed any form of substance use, we are talking about power – in fact it’s revealed in the 12 step programme very clearly, when AA members are instructed to recognise their ‘powerlessness’ in the face of alcohol, or when someone like Gerard Hastings complains about the role international companies play in providing choices for consumers.

This isn’t actually much of an insight, and it’s certainly not original.  At the NDSAG conference, James Nicholls made again the point that comes across so powerfully in The Politics of Alcohol: that alcohol is partly such an interesting topic for the sociologist or historian because it illuminates wider debates about freedom, ideology and so forth.  If we’re defining ‘good’ drinking, we’re saying something about what we think a ‘good’ human being or citizen looks like.

This marks a point that’s more fundamental than my immediate response to Robin Davidson’s presentation at the NDSAG conference about evidence-based policy, or a colleague’s comments about the role of evidence in policymaking in town halls and Whitehall.  I’m not just saying things are political in terms of competing priorities, or politicians having to be popular.  I’m saying issues of addiction and substance use, in a sense, aren’t special at all.  They’re about power, sure, but then so are all questions, if you want them to be: ‘everything, political’.

Policymaking isn’t a case of making ‘good’ or ‘bad’, ‘right’ or ‘wrong’ decisions; it’s about values and principles.  The sooner public health and addiction professionals realise this, the sooner they’ll make an impact on decision-making.

Making imperfect policy for an imperfect world

There’s already been a lot of (virtual) ink spilled discussing the proposal in the Queen’s Speech to ban all ‘legal highs’.  Chris Snowdon and Ian Dunt have already neatly attacked the inconsistency and illiberalism of the proposals, and an article in the Guardian laid out the issues pretty clearly, so I’m not going to talk about the specifics.  (Though it’s worth noting the conundrum that if nutmeg is permitted as a foodstuff, couldn’t a flavoured herb that mimics cannabis also be considered a foodstuff if it could be argued that its primary function is to flavour the food?)

Despite the generally negative tone of commentary on the policy, I remain optimistic.  I’ve said before that ‘legal highs’, along with e-cigs, might provide a catalyst for a reviewed genuine debate on drugs policy, and that’s certainly the case if we just look at those articles by Chris and Ian.

The issue for me, though, is almost more fundamental than their questions of consistency or the Guardian’s worries about whether the proposals will ‘work’ – assuming for a moment that there is just one aim of drug policy: to reduce harm, rather than for government to be tough, or simply to be doing anything at all.

Of course the discussion of whether this approach has ‘worked’ in Ireland is important and interesting, but perhaps the most important point is the limited role evidence can play in this process.  ‘Head shops’ may have disappeared, but that might be simply driving the market underground, which may be more dangerous both in terms of product regulation and quality, and violence and disruption relating to the trade in the substances.  And if fewer people are attending treatment reporting ‘legal high’ use, that might be that they’ve substituted illegal substances (which may or may not be a good thing), or they might be simply more reluctant to report using these substances now their legal status has changed.  In fact, it’s conceivable that reporting use of legal highs specifically was attractive because it meant clients didn’t have to admit doing anything ‘wrong’ (or, more accurately, illegal).

If we try to get to a more direct measure of ‘harm’, we’re still scuppered.  It’s hard to measure chronic harm, like dependence or addiction, as it can take years to be reported or even to develop.  It’s also very difficult to identify acute harm from hospital stats, for example, because it’s unlikely that the data recording will be of sufficient quality to allow you to distinguish between poisonings from ‘legal’ intoxicants and those from other substances.

But that’s almost by-the-by.  All these difficulties with evidence and ‘what works’, along with the apparent inconsistency, highlight what this debate is – perfectly reasonably – about, and why exceptions are the rule.

That is, the key feature of this policy is that specific substances – alcohol, caffeine, nicotine etc – will have to be individually excluded from the ban on psychoactive substances.  This immediately raises the question why these substances?  But there is an answer to that: they are embedded in our society far more than the others.  We probably know more about the effects of these substances on humans than the effects of truly new psychoactive substances, but the real reason they’re legal and not others is an accident of history.

But I’ve read too much Burke and Oakeshott to think that we should be beating ourselves up for not having a ‘rational’ drugs policy.  As I’ve said on this site before, muddling through might actually be the most rational response to the issue of psychoactive substances.  Those accidents of history have happened, and we do have to make policy with all the baggage that comes with past policy decisions; we can’t simply make a clean break and decide on policy from first principles – not to mention the fact that if we’re talking about anything less than global policy then we’ll have to pay attention to what other countries and regions are doing on these issues.

But to say we’re muddling through, and perhaps being a bit irrational, isn’t quite the same as saying we must be unclear or (to use that performative word) obfuscating.  We can be open about the reasons alcohol, caffeine and nicotine are different – and maybe then think about what that means for taurine or e-cigs.

Perhaps there is some consistent principle here about food and drink as methods of delivery (which would say something about the discomfort politicians seem to feel about instrumental use of psychoactive substances), which would then exclude smoking tobacco.  Or perhaps it really is just muddling through with a ‘feel’ for what is right.

Either way, this sort of open debate would reject the fiction that policy decisions are made on the basis of immediate ‘harm’ from a substance; but it could lead to a more holistic discussion that acknowledged the social elements of intoxication and substance use: that different stimulants, for example, mean different things even if they have the same ostensible physiological effects, and so can be legitimately treated differently.  Drunken comportment is socially constructed, as anthropologists of alcohol never tire of observing, and we must make policy in that social setting.

Making policy for a perfect world doesn’t lead to perfect policy, and I would welcome a debate that is more honest and realistic as much as rational and evidence-based.