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.