Thursday, 21 April 2016

Addiction or false consciousness?

I recently read an article about gaming addiction, which inevitably got the usual questions bubbling around my head.  What might this person mean by 'addiction'?  What does this sort of issue have in common with 'drug addiction'  or 'substance misuse'?

If we take the DSM V definition of a substance use disorder, then it's certainly possible to identify that people can play games to the detriment of family and wider relationships, personal finances, career and so on.  And that the activity chosen at some level gives some kind of pleasure or release - even if by the point of dependence that's tinged with guilt or shame, or only amounts to feeling 'normal', not excited, euphoric or 'high'.  That's why I'm never surprised by (or interested in) academic studies or media stories identify how particular activities, or a new substance (such as cheese), stimulate the same receptors as heroin or cocaine.  That's just the body's way of saying you're getting something out of the activity.

So why bother writing about gaming 'addiction'?

Well, the key for me was this article linked this type of addiction with neoliberalism - a brilliant coming together of my two academic interests.  I wouldn't disagree with the writer that lots of people in today's society or economy don't get a sense of meaning, purpose or achievement from their work or wider life.  And that sense of purposelessness doesn't necessarily cause addiction or particular patterns of behaviour, but it can give less of an incentive to break them.  I've just been reading Geoffrey Pearson's The New Heroin Users, and that ends on the note that it's hard to address heroin use in an neighbourhood where use of the drug is widespread and there is mass unemployment.

That unemployment of Lancashire and Yorkshire in the early to mid 1980s could be seen as a direct (even deliberate) consequence of public policy (and let's set aside the fact that the economic policy specifically might be better labelled monetarist than neoliberal).  But it's not immediately clear that 'gaming' addiction is rooted in conditions or policy analogous to this form of (apparently problematic) substance use if the underlying issue is meaning (whether as a result of an unrewarding job or no job at all) or social/community and family connection.

There is certainly a tendency in social policy and related academic fields to say that Thatcherism ripped the heart out of communities, and to link this with close community identity.  And such an interpretation fits with the idea that addiction is a response to a lack of purpose caused by 'neoliberal' economic policy.

The thing is that the image of close-knit communities, held together by work, didn't operate in the same way in all places.  Mining villages were always exceptional in having a single employer, and even the dominance of Raleigh in Nottingham, or Ford in Dagenham didn't represent the life of most people in work under the postwar 'consensus' supposedly destroyed by Thatcher.  There's a reason academics felt the need to conduct ethnography of mining villages, and the idea that 'Coal is Our Life' was a striking title for a book.

This isn't peculiarly 'neoliberal', and might have more in common with the concerns of social commentators and academics in the nineteenth and early twentieth century - people losing their community and social ties (and mores) by moving to cities to take industrial work.  Think of Dickensian tales of London, or Marx's idea of alienation, or Durkheim's idea of anomie.  These were seen to some extent as originating in the division of labour and the loss of traditional community purpose and solidarity particular vocations had given, along with direct, personal, mutual interdependence.  The idea that interactions are based on the nexus of cash owes more to the era of Adam Smith than that of Friedrich Hayek and Milton Friedman.

And this rings true if we think about the history of addiction or substance use.  Public panics about drunkenness were often tied up with broader concerns about the lawlessness of developing industrial cities, and alcohol had a starring role in Engels' description of the hopelessness of life in industrial Manchester.

Misuse of alcohol and other drugs plays a starring role in plenty of literature of the pre-neoliberal world too, notably (though much later than Engels) in the work of Thomas Hardy (at least it's notable for someone who lives in 'Casterbridge').  And computer games hadn't been invented, so we can't find many characters 'addicted' to those.  But we can find people, as in George Eliot's Silas Marner, where a key plot point revolves not so much on a person's dependence on alcohol as what might be called a 'gambling addiction' in modern parlance.  Dunsey's gambling debts as much as his drinking lead him to deception and theft.

And the problems described in literature, media, or medical reports of the period don't sound so different from our own today.  I wouldn't deny that public policy affects the prevalence of misuse, the harmfulness of the consequences, and how easily people can 'recover'.  In fact, I've written about how neoliberalism as an ideology limits the way we approach issues of substance misuse.  But if we label 'gaming' as an addiction, which I might be able to agree with, we can't really see it as a consequence of 'neoliberalism'.  If we do, we risk failing to identify useful, practical solutions.

I have no doubt that many people could live a life more full of 'meaning' - and that, as shown by plenty of addiction treatment programmes, might be achieved as much through religion or philosophy as changing government economic or social policy.  Perhaps it might also be solved, as Marx envisaged, by a communist revolution.  Or perhaps by a return to small, self-sufficient communities as envisaged by the 'Diggers' in the seventeenth century or more recent utopian groups.

But whether that is more desirable than remaining engaged in society as we find it, tweaking our own relationship with it perhaps, and being aware and somewhat detached and cynical is a personal and philosophical question, not one where the causes of addiction are particularly relevant.  (You can perhaps guess where my natural sympathy lies.)

Addiction is more a human failing than one of neoliberalism.  I'm not convinced this search for meaning is something we particularly suffer with under 'neoliberalism'.  In fact, neoliberalism's most vocal critics wouldn't argue that people fail to find meaning under neoliberalism; they just argue that people find it in the 'wrong' things, like consumer products.  And if you're frustrated or sad that people are finding meaning in computer games or trainers, that's not an 'addiction' problem; that's a political or moral problem.  It's when people aren't finding meaning or connection that we can should be talking about 'addiction' rather than false consciousness.

Wednesday, 6 April 2016

Disunity as strength

The government recently published its ‘modern’ crime prevention strategy.  Apart from the bizarre title, given that modernism makes me think more of 1916 than 2016, there’s been some concern expressed that this signifies the end of any joint alcohol strategy.  It seems that alcohol-related crime will now be addressed through this crime prevention strategy rather than something covering alcohol issues as a whole.  And separately HMRC has just published its own alcohol strategy in relation to tax.

As usual, what I want to do here is raise the possibility that this actually might be a more positive development than it at first appears.  The fear from some in the field is that without an overarching strategy for ‘alcohol’ there will be no clear vision for action on alcohol from different government departments.

But why did I just put ‘alcohol’ in quotation marks?  It’s not just because our understanding of this topic is socially constructed – banal as that point is.  It’s that actually we group together issues under the banner of alcohol that don’t necessarily have a lot in common.  I’m not convinced by this banner as a unifying term.

Regular readers of this blog will be bored of me stating that there is a myriad of problems associated with alcohol.  And often that’s all they are – associated with, rather than caused by, the substance.  Those who frequently attend hospital emergency departments often have alcohol misuse disorders, but these are generally amongst several other problems where the line of causality isn’t obvious.  The same applies to many people in alcohol treatment.  It’s not just that seeing them as having an ‘alcohol’ issue is an incomplete picture, it can actively be unhelpful to dissociate alcohol from the other factors in their lives – just think of ‘dual diagnosis’ where substance misuse and mental health teams fail to work together because they see the problem as being rooted in the other discipline.  Recovery from substance misuse in lots of ways isn’t about the substance itself so much as the ingrained behaviours associated with it, and making sure people have the full range of appropriate resources (‘recovery capital’, if you will) to make effective and lasting changes to their lives.

But more fundamentally, even if we were to accept alcohol as at some level the root cause of certain problems, the way in which this happens – and the way in which the people affected understand this – varies hugely.  We know that people are very good at dodging the definition of problem drinking, and this is partly because it’s always easy to point to an ‘alcohol problem that you don’t have, and therefore you can’t be a ‘binge drinker’ or ‘problem drinker’ or ‘risky drinker’ or ‘alcoholic’.

Think of my research, where I was told by a group of people who had been drinking for more than seven hours straight that their drinking wasn’t an issue because they weren’t about to ‘kick off’ like some people would after two pints of ‘Stella’.  Or those who said they weren’t ‘binge’ drinkers and behaved responsibly, but admitted in the same conversation that on the way home from a night out they had set fire to several bins in a park.

This isn’t to condemn these types of drinking, but there’s no question that they would be deemed problematic from certain perspectives, and yet drinkers are able to dodge that classification by pointing to others who are the real ‘binge’ or ‘problem’ drinkers.

I’d suggest this is the curse of thinking about ‘alcohol’ problems.  As I’ve written about addiction before, we can sometimes try to pin down an almost infinite number of problems into one definition.  In the case of alcohol, I don’t think anyone is trying to get that kind of elusive single definition of ‘alcohol’ problems, but the discussion can still have much the same effect.

As John Holmes has persuasively suggested, assuming that the aim of policymakers isn’t abstinence from alcohol or prohibition, public policy would benefit from a debate about what desirable drinking might look like.  There’s a fundamental problem with that idea in this context, though.  An instant liberal (or libertarian) response might be that it isn’t for government to prescribe what desirable behaviour would be; instead it should proscribe activity that is undesirable, defined as being harmful to others.

But in fact, if we’re trying to set strategic objectives, it could be seen as being (unusually for policy) harder to define what is undesirable than what is desirable.  The problem is that even if we could define a single ideal of drinking (and mine might well look different to yours), there would be an infinite number of ways to deviate from this.  It doesn’t get us any closer to understanding that (a) drinking ‘risky’ amounts for health, (b) alcohol dependence, (c) ‘binge’ drinking, and (d) something that might be called ‘alcoholism’ can all be different issues, with different causes, different effects and different solutions.  That’s by no means an exhaustive list, and each individual will have unique circumstances, making the ‘problem’, ‘cause’ and ‘solution’ unique.

But more importantly for my original question of whether it’s worth grouping issues together under the banner of ‘alcohol’, I’m not convinced there’s a great deal to be gained by looking at dependency issues alongside the public health concerns of drinking a bit more than guidelines, alongside alcohol-related violent crime.  These involve different agencies, and different ‘solutions’.

At the risk of repeating myself, that approach offers us an all-too-welcome way of avoiding admitting the problems we might have: at least we don’t have that alcohol problem; which means, of course, that we don’t have an alcohol problem at all.  And that goes for towns, cities and government departments, as much as individual drinkers.  With that in mind, maybe there is some merit in having a crime strategy, a public health strategy, and a substance misuse strategy.  They should all address alcohol-related issues, of course, but maybe there’s a certain strength in disunity.  I’d rather try addressing the ‘alcohol harm paradox’ by thinking about smoking, drinking, diet and physical activity together, than by trying to link up alcohol-related violent crime, recommended drinking guidelines and what should be prescribed for detox.

Friday, 1 April 2016

What do we mean by 'drugs'?

Last week I was at a really interesting conference on psychoactivity and drug policy at Warwick University, and was surprised and honoured to be speaking on the same programme as the likes of Stuart Walton and Toby Seddon.

(Unusually, I was also genuinely impressed by the publicity they included in the conference pack – there’s some great work in the humanities going on there.)

The theme of the conference was prohibition, particularly in response to the Psychoactive Substances Act, which may or may not be implemented in the next month or two.  Given the media coverage of the Act this week, I think it's timely to comment on some of the discussions we had.

(Personally, I can’t see the government not implementing this.  Just because a ‘go live’ date hasn’t been set yet doesn’t mean the policy has been abandoned.)

The position of most people at the conference was opposition to ideas of prohibition, whether from a libertarian or harm reduction perspective.  For me, this debate centred on the concept of ‘drugs’.

Fundamentally, many people’s opposition to current drug policy is rooted in a feeling that it is unjust to have some substances legal and others illegal, when there isn’t a great deal to choose between them in terms of their inherent chemical or pharmacological properties.  Why is alcohol legal and MDMA not?  Chocolate and tobacco, but not cocaine and cannabis?  Julian Buchanan is a particularly vocal exponent of this position, using the phrase ‘drug apartheid’ to describe how some substances are considered consumer products (tobacco, alcohol, etc), others medicines (methadone, morphine, sativa), and others ‘drugs’ (heroin, cocaine, LSD).

At the conference, Toby Seddon suggested that, if we try to understand what that last category of ‘drugs’ means, the only thing these substances have in common is the way they are regulated.  They don’t have similar origins, histories or effects (in terms of either mind-alteration or health harm).  He suggested that any attempt to prompt a rethink of drug policy would need to question that concept of ‘drugs’, which currently simply reinforces the ‘apartheid’, as Julian Buchanan would put it.  If people keep referring to ‘drugs’, then they’re using a category that only functions as a tool to maintain regulatory distinctions between substances – precisely the distinctions they want to question.

An interesting presentation came from Kojo Koram, who offered a reminder of how these distinctions can be entrenched.  The 1961 UN Single Convention on Narcotic Drugs uses the word ‘evil’ multiple times in its preamble (p.23 in the pdf here) – a word that doesn’t appear in the comparable sections of conventions on slavery, or even genocide.  It is this moral framework around ‘drug’ use that helps maintain the status of certain forms of use (whether classified as pleasure-seeking, self-medication, addiction or anything else) as problematic.

Stuart Walton argued that what is required is a public challenge to these assumptions and this framework.  Those in positions of influence should speak and act in accordance with their beliefs while they are in a position to change things; not simply afterwards, once they have safely retired or changed jobs.  And people regardless of their power or influence should be open about their use of substances past and present – as also encouraged by Carl Hart – to help break that association between ‘drug’ use and ‘evil’.

My presentation was somewhat different, but focused on the same ideas: that the concepts we use to understand policy are hugely influential.  Given the tone of the event the night before and the conference itself was strongly against what was defined as ‘prohibition’, and highly critical of the Psychoactive Substances Act, I wanted to present some thinking that might be not simply critical, but constructively critical (thinking of the ever expanding list of rules of drug policy and Robert Maccoun’s suggestion that “Experts like to have it both ways; we hold the government to higher standards of proof than we apply to our own policy opinions”).  I wanted to ask whether there could be a sympathetic interpretation of the Act.

I’m not sure I entirely believe my own case, but I wanted to offer a bit of nuance to the claims being made.  My point was relatively simple: ‘psychoactivity’ has replaced ‘harm’ as the concept by which drug policy in the UK is justified.  ‘Psychoactivity’ might not be easily definable, but it is potentially more transparent and realistic than ‘harm’.

Before the Act, UK drug policy was structured around the concept of ‘harm’, and this is still the organising principle for much reform activity – the claim that we should legalise and regulate, or at least decriminalise, ‘drugs’ in order to reduce the harm to users.  The Advisory Council for the Misuse of Drugs (ACMD) was there to offer the government expert opinion about the relative harms of different substances, which would consequently be controlled to varying degrees using the classification system (Class A, Class B, Class C).

The Act replaces ‘harm’ as a way of regulating substances with ‘psychoactivity’.  Substances would no longer be assessed based on their likely harm to users; they would be banned regardless of harm if they were being bought or sold as having a psychoactive effect.  Of course this would in principle ban alcohol, nicotine and caffeine (not to mention several other substances) so explicit exceptions have to be made.  Originally, I thought this might open out discussion to consider why those substances are allowed and others aren’t – and this has happened in public debate, but the government’s position hasn’t changed.

But my argument in the conference paper was that this position might actually be justifiable based on research from history and the social sciences.  First off, the idea of ‘harm’ from substance use is hugely complex.

It could be harm to others, through use of the substance itself, as in passive smoking, or more indirectly through what Liam Donaldson called ‘passive drinking’.  It could be harm to the user directly – but this could take a variety of forms.  It could be that there’s a risk of death, or perhaps a risk of disability or sickness.  And these risks could be from chronic exposure to the substance, or from particularly severe or problematic acute exposure, or particular patterns of use, or through combination with other risky substances or behaviours.  (Here I'm mostly paraphrasing the discussions about alcohol harm at the recent Alcohol Research UK conference.)  Interestingly, when we think about drug deaths we tend to think about overdoses, while alcohol deaths tend to be seen as due to chronic diseases, the result of heavy use sustained over several years.

So you can see that any attempt to compare the potential harm of different substances is fraught with difficulty.  It will inevitably mean looking at a whole range of factors, and weighting them against each other – as you can see from this attempt by David Nutt and colleagues.  Just look at the sheer number of colours there have to be to identify all those potential harms.

A further complication is that these harms aren’t guaranteed.  As the Police are fond of pointing out in relation to new psychoactive substances, using certain substances might be described (if you’re prone to more than a little exaggeration) as ‘Russian Roulette’.  The key to this is the idea of ‘risk’, the problem being that we humans aren’t terribly good at understanding risk – as shown by the confused debate around the recent new alcohol consumption guidelines.  All this means that it’s difficult to put a single number on the harmfulness of a substance.  And that shouldn’t be a surprise to any historian or sociologist of drugs - though for a slightly different reason.

Think of Howard Becker writing about learning to get high from marijuana; Mary Douglas talking about ‘constructive drinking’; Norman Zinberg talking about drug, set and setting; MacAndrew and Edgerton talking about ‘drunken comportment’; or Dwight Heath on the anthropology of alcohol use.  All these authors note the importance of patterns of consumption and the culture or learned behaviour around substance use in determining both practices and harms.  Of course this isn’t to deny what might be called ‘objective’ effects or harms of substances; the point is that how these translate into harms isn’t straightforward.  When considering the likely harm of a substance in a given society, we should be thinking about the norms around its consumption.

This isn’t an original or blinding insight, but it is worth remembering, as it means that policy can’t – or rather shouldn’t – really be made on the basis of a purely scientific assessment of a substance’s properties.  But what’s that got to do with psychoactivity?  Well, the way that concept is applied in the Act is precisely how Toby Seddon or Julian Buchanan would identify ‘drugs’ in policy discussions: it means all those things that are illegal (or we want to be), since it explicitly excludes alcohol, nicotine and caffeine from the category.

And maybe that’s justifiable, given the evidence around harm and social context.  There’s a legitimate argument that given a society’s history and present circumstances, different substances with ostensibly similar pharmacological properties shouldn’t necessarily be regulated in the same way.  This is the thinking behind dividing societies into ‘wet’ and ‘dry’ in relation to their attitudes to alcohol.  Some societies have developed stable ways of dealing with well-established substances, but might not be able to have the same social control over a new substance.  I think this is a simplification of the different ways in which we relate to alcohol, but it's a pervasive model, and there should certainly be some acknowledgement of the importance of social context to harm.  The point is, policy based on the sociological and historical research on intoxicants wouldn’t necessarily apply a single standard to all relevant substances.  And a scientifically determined concept of harm, based on the inherent properties of a substance, wouldn’t be able to make these distinctions.

If people have quite different understandings of two very similar substances, it’s reasonable to acknowledge those understandings as misguided or irrational – but it would also be rational to control the substances in different ways to take account of the different way people react to them.

In practice, this is how the Government is using the concept of psychoactivity: to designate substances the government thinks, rightly or wrongly, we're not in a position to safely legalise, due to the social context.  (Or perhaps I should say, they're not in a position to safely legalise, due to the political context.)  And based on the scientific, historical and sociological evidence, there is a sense that psychoactive substances have dangers (even alcohol is ‘no ordinary commodity’), and, because of cultural factors, we can’t treat all substances that have the same apparent level of psychoactivity or toxicity in the same way.

This doesn’t mean that the UK government is right to ban MDMA, LSD, nitrous oxide and a myriad of other substances.  But it does make the apparent inconsistency a coherent position.  It is partly historical accident (and as Virginia Berridge and others would point out, a relatively recent historical accident), but there’s no avoiding the fact that currently illegal substances occupy a distinctly different position in our society to those longstanding legal substances such as caffeine, alcohol and nicotine.  Of course the fact that other substances have been legal – or differently regulated – in the relatively recent past suggests that it’s not unrealistic to imagine such a situation could be instituted again.  And that might not be a bad thing.  I’d hoped that those ‘disruptive innovations’ of e-cigs and NPS might prompt a rethink of current drug policy, and to a certain extent it’s disappointing they haven’t.

But to rail against the Psychoactive Substances Act as being incoherent, inconsistent or hypocritical is not only to subscribe to a naively rationalist view of policy, but also to neglect the hugely valuable contribution of history and social science to the study of intoxicating substances.  We can't – and perhaps more importantly shouldn't – rank substances according to some apparently objective, unchanging, ahistorical notion of harm.

That's perhaps an oversimplification of what Nutt and colleagues, and various campaigners have been trying to do, but I'd still suggest that's the frame by which they justify their approach.  And it's not only unrealistic; I'd suggest it's actually undesirable as an ideal.  If alcohol isn't an ordinary commodity, new psychoactive substances are even less so.  So perhaps ‘psychoactivity’ in the new Act is simply a synonym for ‘drugs’ as colloquially understood, as reflects the continuing influence of ‘drug apartheid’ – but we should be careful of extolling the benefits of a pure, objective, rationalist drug policy: there’s plenty of social research that suggests this wouldn’t fit with how we actually understand and use different substances.

It may not be a perfect policy, but let’s not be too quick to dismiss the Act as unthinking or arbitrary.  Maybe the Act, for all the critique, actually presents a more coherent approach to drug policy than ‘harm’, which simply points to an apparent inconsistency between legal and illegal substances.

Update 06-04-16:
You can hear me discussing some of these issues with Steve Harris of BBC Radio Solent on their 'Breakfast in Dorset' programme on the day the Act was meant to be introduced - but wasn't - here.