Monday, 29 October 2018

Are compassion and connection the answer to drug policy debates?


Two people I have a huge amount of respect for – Suzi Gage and Harry Sumnall – have just published a paper encouraging us all to have a bit more restraint when discussing the implications of the Rat Park experiment.  Just like the original author, Bruce Alexander, did, in actual fact.

I was familiar with the experiment somewhere back in the mists of time, but (setting aside Bruce Alexander’s appearance at the 2016 New Directions in the Study of Alcohol conference) the reason it’s on my radar now is that Johann Hari and others have used it to campaign for the legalisation and regulation of drugs.

For those of you who are interested in finding out more about the experiment, I’d recommend Suzi and Harry’s article.  Basically, the study is typically seen as showing that a rat’s propensity to get ‘addicted’ to a drug (morphine in the case of Bruce Alexander’s work, but others have used cocaine) is not simply dependent on the drug, but their environment.  Put rats in bare, individual cages and they’ll use intoxicating drugs to the point of incapacitation or even death; put them together in a ‘Rat Park’ with other rats and entertainment and they’ll pretty much ignore the drugs.

The problem is, of course, that it’s more complicated than that, and in any case it’s hard to extrapolate from a small animal study to a global policy for humans.  It’s often overplayed because it’s an eye-catching story.  In itself, the research isn’t miles from the general consensus about what causes issues like addiction: a mixture of the substance, the person and wider circumstances.  The ‘biopsychosocial’ model, if you like.

The point of all this discussion is that reading the article reminded me I had recently made the effort to read Johann Hari’s Chasing the Scream in full.  I felt guilty at criticising him on the basis of TED talks or newspaper articles without actually having read the whole book.

I’m not particularly negative about the book.  It’s well written and the interviews and storytelling are engaging.  I also want to believe the conclusions, and I like the way he writes about how he reached them, and the uncertainty about whether they hang together.  I largely agree with the conclusions.  I think the world would be a safer place if more drugs were regulated and available through legal routes, whether prescribed or sold.

Unfortunately, Hari was right to be concerned: the conclusions don’t actually hang together.  I know the book isn’t new, and other people have analysed it before me, but I it’s been a useful exercise for me to think all this through, and it’s important for our debates about drug policy.  It can feel like we’re at a fork in the road at the moment, not just seeing possibilities for change, but real change itself.  Cannabis is legal for recreational use in countries around the world, and more and more places are operating decriminalisation, either in theory or practice.  The arguments and claims we make for these policies, are important.

So just noting a few of the issues with Johann Hari’s claims, he can’t seem to decide whether drug use is exciting or boring – and he sees this as crucial to the solution.  So he quotes John Marks, who prescribed injectable heroin on the Wirral in the 1980s, as saying: ‘I try to make my clients realise that what they’re doing is boring, boring, boring.’  Except that’s not (always) the case.  And it’s not what Hari says elsewhere in the book.  Using heroin can be exciting – and not just in terms of the chemical ‘high’.  As Steve Wakeman has powerfully described, the routine of getting together enough money, making the deal and using the drugs provides a focus and some excitement to the day, and also offers people a sense of expertise and achievement.  It can also provide a community.

As I say, Johann Hari knows this.  When he quotes John Marks on p.211, he has already quoted Bruce Alexander on p.176 saying that when the life of a heroin user is compared with what might happen if they got a ‘McJob’ or became a janitor, it seems ‘really exciting’.  Hari doesn’t have to agree with everyone he quotes, but he does need to balance different perspectives up against each other.

Of course it’s possible that, following the idea that people ‘grow out’ of most patterns of substance use, heroin use is exciting to start with, and maybe for many years, but at a certain point there comes a time when it seems ‘boring, boring, boring’.  But as the Bruce Alexander point shows, this depends on what else is on offer.  It also means that one approach won’t make sense for everyone.

This has important consequences for policy.  Heroin assisted treatment (HAT) is more likely to work if the alternative isn’t seen as exciting – because HAT will never be exciting in that way, as Steve Wakeman has again described so well.

So we’re not clear from this book what treatment we should be offering people, but perhaps that isn’t much of a criticism.  This is really a book about the global ‘war on drugs’.  So let’s think about drug policy more broadly.  Hari suggests that use of substances isn’t down to access, but in fact there’s plenty of evidence that use of alcohol (and in fact other drugs) goes up and down depending on how accessible it is.  Some might argue that overall levels of substance use stay the same, people just switch from one substance to another (even across legal boundaries).  However, we know that overall substance use varies over time, and this is partly about access and affordability.  In many countries, the interwar years saw slumps in alcohol use not because everyone was switching to other drugs, but because money was tight and it was harder to get hold of a drink because of stricter controls or even prohibition.

But citing Bruce Alexander again, Hari states: ‘The answer doesn’t lie in access.  It lies in agony.  Outbreaks of addiction have always taken place … when there was a sudden rise in isolation and distress – from the gin-soaked slums of London in the eighteenth century to the terrified troops in Vietnam’ (p.228).

There are two problems with this approach.

First, it’s not clear that high levels of substance use are associated with agony so much as affluence.  Perhaps affluence comes at times of change and upheaval, but the relationship is more complicated than that.  Of course, ‘addiction’ is a problematic concept, and it might be that if we define it tightly enough then we can see that instances increase at times of ‘agony’.  There’s certainly no doubt that difficult experiences can drive people to substance use.  But dealing only with ‘agony’ – or even seeking the prevention of ‘agony’ would leave us with a pretty narrow, ineffective drugs policy.  Too often, the book slides into describing drug use as inherently problematic (e.g. pp.241-2) – and then moments later talking about the inevitable human desire for intoxication.

Second, availability is a key factor that is part of the mix.  The ‘gin crisis’ (or rather the perception of a crisis) occurs not simply because of an increase in agony, but also because of availability of a particular product, which has been developed through technological innovations and the confluence of foreign policy (gin as a patriotic Protestant alternative to French brandy).  Use of heroin amongst American troops in Vietnam was partly the result of it being available.  Why not other substances?

The response to this is that the substance is secondary: whatever is affordable and available will be used to soothe the pain.  But was there less pain in the ‘dark ages’?  During the English Civil War?  During the World Wars of the twentieth century?  We’re drinking more now.  If drinking follows pain, that simply wouldn’t be true.

And, crucially, we do drink despite it being legal.  Campaigners might see legalisation as ‘a drama reduction programme’ (p.263), but the most important bit of drama relates to the murderous crime drama that is the production and distribution of drugs.  There’s plenty of drama in consumption even when substances are legal.  If the ‘fun’ were taken out of drug use, wouldn’t people move onto something else (like the ‘carnival of crime’) to get it?

These might seem like flippant points, but they have important implications for policy.  ‘Addiction’ is not the only problem related to substance use, and it doesn’t only relate to ‘agony’, though this can be an important factor.

To challenge this ‘agony’, Hari’s rallying cry is that the opposite of addiction isn’t sobriety, but ‘connection’ (p.293).  ‘A compassionate approach leads to less addiction’ (p.252).  His hope is that people and politicians of all stripes will begin to see that drug policy ‘isn’t a debate about values’ but rather a debate about harm.  ‘We all want to protect children from drugs’ (p.252), for example; we just disagree about how best to do this.  I’ve written before about how ‘harm’ is extremely hard to define.  In fact, it’s a weasel word that makes us think we agree when we don’t.

I don’t want to downplay the importance of Hari’s claims with these criticisms.  When he describes the issues surrounding the criminalisation of drugs and the broader social and economic deprivation that often goes with them (p.238), we could be talking about many areas of the UK today: if we take away the drugs, what is a person potentially left with?  No job, or realistic prospect of getting one.  No stable, safe, warm and dry accommodation.  No supportive personal relationships.  Of course this is a particularly negative view, and everyone carries assets with (and within) them, but the reality is that ‘recovery capital’, just like all other forms of capital, is not evenly distributed across society.

But the general point regarding legalisation is that it would reduce stigma.  Hari quotes Joao Figueira who suggests that people who’ve got into problems with alcohol were always treated as ‘friends’ and given support, and now the same humanity and sympathy are offered to people who use illicit drugs (p.250).  But I don’t recognise that in our approach to people in the UK today.  Public debate, and even plenty of private interactions, often don’t show humanity and compassion to people who run into issues with any substance, including alcohol.  (If you doubt my position, take a look at the articles and comments on the Dorset Echo website from time to time.)

Legalisation is not an easy answer to reducing stigma.  In fact, as substances become more available, and more people use them without problems, the potential judgement might become more harsh.  At the moment, many people have misconceptions that illegal drugs are immediately addictive.  If they were disabused of this notion by seeing plenty of people using them recreationally, perhaps they would identify the problem as residing not in the substance but the individual.

I agree that compassion could reduce problems surrounding drugs, or at least help us deal more effectively with them.  The issue is that compassion, and the approach Hari sees as compassionate, need some serious work to make them politically acceptable.

Understandably, Hari seems to be writing for the people who are going to read his book: bluntly, middle-class, liberal, intellectuals.  When he claims that we all want to reduce harm, I don’t recognise that in our political culture today.  There are plenty of people who see punishment not as a form of rehabilitation that may be more or less effective, but as something that has a moral purpose of its own.  When Hari suggests that ‘most of us don’t object to drug use in and of itself.  We worry about the harms caused by drug use’ (p.266), I think he underestimates the public opinion challenge surrounding legalisation.  Even drinking to intoxication is condemned in our society, and that’s making use of a legal drug.  Use of illicit intoxicants is far from acceptable.

I know this is changing, and there are organisations like VolteFace who are making waves in changing the terms of debate, but this is hard work that needs to be done carefully, and it can’t be done simply by calling for compassion or believing that intoxication is acceptable.

Reading the book reminded me of why I find this kind of line on drugs policy disappointing: it’s looking for a magic solution to a multifaceted issue (or, more accurately, a whole range of issues) and overplaying its hand.  That’s why the article by Suzi and Harry reminded me of my thoughts on the book, which I’ve meaning to write down for a while: we need to be really careful about what we’re promising, and the problems we’re trying to solve, otherwise we could end up in a worse position than we’re starting from.

3 comments:

  1. Great piece Will. Very thoughtful. I'm guilty of picking stuff that supports my pre existing world view and turning a blind eye to any inherent problems. It's great to have you and Harry and Suzi and others to act as our guide through these times of policy based evidence making. Thank you

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  2. Data shows pharmacotherapy works in OUD. Evidence confirms only half those in need use the treatment system. Those that do get inadequate doses or infrequent treatment sometimes for all kinds of reasons

    First step - use innovation to enable best pharmacotherapy. New depot products have strong evidence of efficacy and safety. I think focusing on the practical is very important.

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  3. Another balanced piece that endorses facts. Unfortunately, populist political and media driven rhetoric feeds much in public opinion which in turn drives policy.

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