As you could probably tell if you read my last blog post, I’ve been thinking a lot about what the ‘problem’ (or rather what problems) in relation to alcohol it is that policy and treatment are trying to solve, and whose responsibility these might be. An analogy that’s often bandied about is one of wider health or healthcare – addiction is a health, not a criminal justice, issue – particularly if we note parallels with mental health.
One of the best pieces I’ve read about mental health care was this article by Hannah Jane Parkinson. It starts by considering the common analogy that we don’t think of people with broken legs the way we do people with mental illness, and if we did there would be less stigma and people would be more likely to receive effective treatment. But the challenge she puts back is that, in fact, mental illness isn’t much like having a broken leg. I agree, but, being a bit of a contrarian, I want to suggest the analogy might still be useful – or at least some form of analogy with physical health.
If you look at many physical health conditions, although the pathway won’t be immutable or the same for every patient, you can be given a pretty good idea of what it’s likely to look like, and where the decision points might be along the road. I’m not sure we’ve always managed that in substance misuse treatment services.
But it’s not just about that kind of learning. If we think a bit differently, then an analogy like a broken leg or the common cold does actually make a lot of sense – and perhaps even helps illuminate who might be seen as responsible for the various elements of prevention, vaccination, rehabilitation and cure (or however we badge things).
Take the common cold, which is a regular source of frustration to me: why haven’t we found a cure yet? Why did we stop the trials at l(well, near) Porton Down? (No, not those trials.) Well the answer is that what we see and diagnose as the common cold could be seen as a set of symptoms; there are many different viruses that actually cause them. And even if two people have the same virus, it might affect their bodies in different ways: when I get a cold it always starts with a sore throat; for other people it’s sneezing or a runny nose.
So let’s apply this as an analogy to substance use disorders (SUDs). Think of that DSM-V definition. It, just like our understanding of the common cold, is a set of symptoms. And it’s plausible to see the cause as similar: a range of things lead people to use in these ways, even if they can be grouped together in the same way that cold viruses can be (as adverse childhood experiences, for example). And what that disorder looks like will be different to different people. Not everyone has a sore throat when they get a cold, and not every DSM will be ticked for substance use disorders. And, importantly, not every cold you get has the same symptoms – sometimes there’s no blocked nose, sometimes there is – and so not every episode of substance misuse will look the same even for the same individual.
So that tells us how SUDs look like common colds. But what can we learn about how we address them?
First off, let’s think about prevention. We talk about good habits: coughs and sneezes spread diseases, wash your hands, don’t go into work needlessly if you’re ill, get lots of sleep, etc. There are precautions you can take as an individual to reduce the work to yourselves and others. The same is true for SUDs. So local and national government has a role in making sure social structures and opportunities don’t foster illness.
In terms of treatment for a cold, we just relieve the symptoms. We take medication like Lemsip. We avoid making it worse, maybe by taking some time off work.
We can do the same for SUDs – though maybe methadone is a more likely medication than Lemsip, and harm reduction interventions include needle exchange rather than honey and lemon. This is where substance misuse treatment services come in.
But none of that stops me being grumpy about the common cold, and wondering if we couldn’t do more. Why did we stop those experiments at Porton? Well, apart from the ethics, from what I can tell it was felt that although the symptoms looked similar, the viruses were too different, and mutating, for us to develop a single treatment or vaccine.
Instead, what looks more promising is accepting there probably won’t be a vaccination, but developing medications that, rather than just easing the symptoms, stop our bodies from providing what the virus needs to replicate.
Interestingly, and encouragingly (or frustratingly, depending on your outlook on life) none of this is alien or new to substance misuse services. We can try, but we won’t ever completely stop people being exposed to risk factors for substance misuse. So when they are exposed, we want to make sure they have resilience, and then decent self care if they’re in an episode of misuse. Then, we can provide medication – Naltrexone, for example – that reduces the chances that someone’s exposure will lead to another episode.
So maybe that analogy with physical illness isn’t terribly useful – but not because it’s not accurate; rather it doesn’t tell us much we don’t know already. (So this was definitely a worthwhile blog post…) It perhaps tells us that we sometimes underestimate how complex and inexact medical science is, even for apparently straightforward ‘physical’ illness.
And it’s not just the common cold. Let’s go back to the broken leg analogy. That is, effectively, a symptom.
There are lots of potential causes of a broken leg – including skiing and playing rugby – and lots of people will carry on putting themselves at risk after they’ve broken their leg once and it’s healed. (Perhaps, without being too flippant, being a rugby player is a chronic, relapsing condition that’s harmful to your health and family relationships?)
We can try to reduce people’s exposure to risk, and we can try to reduce their risk by ensuring diet and behaviour gives people relatively strong bones, but people will still break their leg. And once they have, sometimes it’s easily healed, sometimes not. Sometimes there are long term consequences (you’re unable to play rugby again); other times life is pretty much back to normal.
The treatment will involve a number of different professionals, even if what is being treated is just the broken leg itself. (Think of doctors, nurses, drug workers, social workers etc helping with SUDs.)
But if the broken leg is a symptom of something broader, like osteoporosis, and just stopping playing rugby won’t be enough to prevent it happening again, then other specialists might need to get involved – and only then are we talking about something more than symptomatic relief.
Fundamentally, none of this is terribly illuminating, I must admit. And what I certainly don’t want to do is undermine the crucial point that treating mental health or substance use disorders is like ‘treating’ a broken leg. They’re not, exactly – though the analogy can actually be comforting: we do what we can. What this discussion can remind us is that maybe substance misuse isn’t quite the special case we might think it is. Medicine, even for physical health, isn’t in practice an objective science so much as a personal, human and nuanced practice of care. Sometimes it’s nice not to be special.