The disease of black and white thinking about addiction

Today (#OurDay) I was at an event in Bournemouth where we were discussing how we could get the different services to work efficiently and effectively together, when there’s decreasing resources at the same time as many of the people who need support are facing increasing challenges, such as unstable housing, complicating health conditions, unemployment, benefits cuts and so on.  As one person described it, it’s a ‘perfect storm’.

This isn’t news, and although the suggestions made by staff were excellent, I want to focus on some conversations I had outside the main discussions – over lunch.

The first thing to note is that despite the astonishing passion and dedication of these staff, who are quite simply not paid enough, the environment they are working in is taking its toll: those decreasing funds and increasing challenges mean people are struggling to see that they’re genuinely making a difference.  Is it just pushing water uphill?  At one point do you decide to stop propping up a system you don’t believe in?

And that brings me onto a bigger point about beliefs that I want to focus on here.

I was surprised that there was still considerable passion not just in the delivery of treatment, but in the recovery / harm reduction debate.  I had naively thought we’d buried the hatchet, but it’s very much alive in terms of how people see the decisions that different organisations and clinicians make.  In a sense, that’s not surprising, though, and it’s partly the fault of commissioners (and politicians) for doing one of two things.

First (and this is my own typical failing) we’ve sometimes been guilty of ducking the issue, of imagining that just saying things like ‘evidence based’ or ‘Orange Book’ will dissolve any conflict.  It won’t.  We should be savvy enough to know that there’s plenty of wiggle room in NICE and PHE guidelines, and there’s always that black box of ‘clinical judgement’.

Second, and conversely, we’ve sometimes been too definite.  Sometimes issues have been presented as ‘black and white’, with a proposal being ‘right’ and all other options ‘wrong’.  No wonder, then, that as the goalposts seem to be moved staff feel betrayed or lied to: if the previous policy was ‘right’, surely this one is ‘wrong – or vice versa.

We should all be a little more cautious when ‘selling’ policies, and open and honest about our motivations and the limits of our knowledge.  (We should also obviously be careful not to introduce any genuinely ‘wrong’ policies in the first place.)

The problem is that when someone is presenting something as a black and white issue, and you’re not sure you agree with their position, it’s easy to get caught in that same binary way of thinking – when what I’d prefer with most of this is to suggest that there isn’t a single right approach, and if we want to talk about services that are tailored to the client, we need to genuinely listen to them.  A one-size fits all approach, whether from a self-proclaimed ‘recovery’ or ‘harm reduction’ perspective is likely to be unhelpful for a number of people.

If this all sounds a bit cryptic, that’s fine.  My real point is something almost trivial about the theory of addiction.  (Which of course is never cryptic.)

In my experience of discussions about ‘addiction’, certain high-minded academics critique the ‘disease model’ of addiction, and possibly even the whole concept.  Then they are advised that the disease model, as championed by NIDA, is valuable because it helps stop addiction being stigmatised.  If people are ‘ill’ rather than ‘bad’, then surely there’s no reason to marginalise them and not offer reasonable healthcare and support?

It always feels to me that critiques of the disease model are therefore labelled as abstract, idealistic, and not in touch with ‘real’ politics or treatment.  This is brought home even more by the close links between the disease model and the ideas of fellowships like Alcoholics Anonymous.

Of course this is naïve on two counts.

First, academics can also have lived experience.  Marc Lewis, who co-wrote one of the pieces linked to above, makes no secret of his.  Indeed, it’s his experience that led him to a different perspective on the issue.  And more broadly, these aren’t simply abstract, academic debates; they can shape policy and treatment.

Second, the idea that being ‘ill’ isn’t stigmatising is absurd.  Any number of diseases and illnesses have been considered moral failings, or simply dangerous and therefore stigmatising, from leprosy to cerebral palsy, to HIV to name just a few.  We don’t manage to treat everyone who is ill with dignity.

Is the disease contagious?  Is it somehow caused by someone’s ‘lifestyle’ (or that of their parents)?  These are key questions not just for the stigma surrounding addiction, but many other illnesses.  And they’re not easy to answer.  (If recovery is contagious, then isn’t addiction?)

But it seems to me that this remains the frame of the debate: brain disease a realistic, pragmatic, stigma-reducing idea; critiques perhaps well-intentioned, but abstract and academic.  Criticising the disease model is seen as a hobby of abstract academic thinkers not grounded in the real world.  (Maybe that’s me being oversensitive, but stick with me.)

That’s why I was surprised to hear critics of ‘harm reduction’ (self-confessed advocates of ‘recovery’) also criticising the disease model.  But of course this made perfect sense.  For them, the reliance on methadone (and an emphasis on ‘optimal dose’ in the Orange Book that is relatively high compared to much practice) represented a medicalising of addiction based on a disease model.  If you diagnose a disease, our standard medical approach is to prescribe, well, a medicine – in this case methadone.  But methadone is nothing like an antibiotic, or steroid.  It doesn’t in itself fight an infection or reduce swelling; it feeds a physiological dependency.

I don’t really want to get drawn into the details of this debate.  It would take too long and the evidence isn’t always perfectly clear.  It would also mean conducting a debate in ‘bright lines’ when the reality is a little more muddy.

I just want to pause on this point: recovery advocates can also be critics of the disease model.  This is of course completely coherent, and maybe it’s only me who’s intrigued, but it highlights that these debates aren’t simply black and white.  If we had to choose a ‘side’ between ‘harm reduction’ or ‘recovery’ we might find ourselves alongside with some people we don’t agree with regarding the very nature of ‘addiction’.

An overly prescriptive idea of ‘right’ and ‘wrong’ approaches to treatment actually contains the seeds of its own downfall.  If your enemy’s enemy is your friend, you’ll find that, actually, we’re all friends.  We shouldn’t be choosing sides.  Not when there’s bigger battles to fight – like that perfect storm.