From pleasure to vice to addiction

I’ve been reading quite a bit of fiction and non-fiction about substance use and ‘addiction’ lately, and some of the latest things have sparked me to wonder if we think carefully enough, or fundamentally enough about the issues.

I’m going to focus here on David Courtwright’s new book The Age of Addiction: How Bad Habits Became Big Business, but the points apply equally across a lot of the debate currently.  Although this reads a bit like a review, I’m trying to make a broader point that we’re sometimes not as clear as we could be about what the problem is and how we’re trying to solve it – and this is important if we’re going to develop effective public policy.

Courtwright’s book is a whistle-stop tour through the history of substance use, from prehistory and the development of agriculture through to the industrial revolution and more recent developments such as digital technology and online markets and interactions.  Although not mentioned in the title of the book, the argument hangs on a couple of key concepts.  He’s concerned with ‘vices’ and how something he calls ‘limbic capitalism’ has made us more vulnerable to developing these.

Courtwright argues that there are parallels in the ways we can get into trouble with different substances, whether we understand them as ‘drugs’ or not, and behaviours like sex and gambling.  What start off as being ‘pleasures’ can transform into ‘vices’ and eventually ‘addictions’.  In this way, the book is about sugary food and drink as well as gambling as much as more familiar issues grouped under the banner of ‘addiction’ like alcohol and other drugs.

Courtwright suggests that with industrial capitalism certain pleasures became more attractive and available, as urbanisation fostered psychological as well as geographical disruption.  For example, drink was more available in cities, you could indulge in pleasures with less fear of judgement as there are more anonymous spaces, and you had more reason to as there was less social connection and the work and living conditions were less stable and rewarding.  So the industrial age was one of vices, not mere pleasures.

But Courtwright’s warning is that we have moved beyond this form of capitalism and its associated vices to a new form – ‘limbic’ capitalism – and the issues emerging deserve the label of addiction, not just ‘vice’.  The word ‘limbic’ refers to the ‘limbic’ system, an idea Courtwright takes from the work of people like  Daniel Kahneman.  The idea is that humans have two ways of acting: through rational deliberation, making use of their ‘head’; and through more automatic mechanisms, often labelled as a ‘gut’ reaction.  It’s the ‘limbic’ system that’s responsible for the latter.  (Incidentally, I think Dan Gardner is more relevant in this context.)

Thinking about these two systems is one way of understanding the paradox at the heart of the concept of addiction: that we can knowingly act against our best interests.  When we employ our ‘head’ to think about things, we know a particular course of action is unwise, and we want to avoid it; but when, in the heat of the moment, we rely on our ‘gut’, we make a mistake – or a ‘lapse’.

Courtwright’s contention is that capitalism today is increasingly efficient at mobilising the ‘gut’ at the expense of the ‘head’, meaning that ‘addiction’ is more common.  Examples include the formulation and marketing of unhealthy food and drink and the design and delivery of computer games and social media through the internet and mobile devices.

The elegance of the this argument makes it attractive, though I would take issue with some of the claims.  I don’t want this to be a comprehensive book review, so I won’t go into detail here, but I worry that this view idealises the past and misrepresents the nature of addiction.

Prehistoric and agricultural societies were not innocent worlds where ‘pleasures’ never transformed into ‘vices’ – and although that isn’t what Courtwright is saying, there’s something about the argument that suggests there was some golden age where we had our ‘guts’ and ‘heads’ in balance.

Crucially, the ‘gut’ and ‘head’ are not entirely separate and we can’t quite explain ‘addictive’ behaviour in this way.  Representing two systems like this risks reproducing a Cartesian mind/body dualism, which has been critiqued to death.  While a Cognitive Behavioural Therapy (CBT) approach to issues around substance use might take the approach of getting people to actively reflect using reason, that isn’t quite the philosophy behind other approaches that many people rely on, including Alcoholics Anonymous (AA).  These approaches to recovery aren’t simply about prioritising the ‘head’ over the ‘gut’; they’re about re-training your ‘gut’.  Just as genetics and early experiences help determine what ‘pleasures’ we are most vulnerable too, so we can ‘re-train’ ourselves to form different tastes and habits.  The reflective can become automatic – so much so that the reformed smoker or meat-eater can find the smell of cigarettes or frying bacon viscerally disgusting.

But in a sense that’s by the by for Courtwright’s argument.  It could still be claimed that this is prioritising the ‘head’ in order to understand what is genuinely in our best interests, and then we can use the ‘head’ to slowly turn round the ‘gut’.  (I’m not quite convinced by this; encouragement to fake it till you make it and just keep attending meetings don’t feel exactly ‘rational’, or something the ‘head’ can entirely justify.)

But more important than these details are the issues of language and concepts.  Courtwright isn’t exactly clinical in defining what makes an erstwhile pleasure a ‘vice’ or ‘addiction’.  I suppose he would say that a vice is an indulgence in a perhaps fleeting pleasure where, at least in the long run, either you or someone else around you is harmed, and this can be understood as an ‘addiction’ where there is some sense of compulsion.

And perhaps this lack of clarity is forgivable in what is essentially a book outlining a grand narrative.  At some level my frustration with this is simply a matter of personal style and preference.  The sort of books and authors Courtwright is drawing on don’t do a lot for me – Kahneman, Steven Pinker, Yuval Noah Harari, Thaler and Sunstein and so on.  For me, too much gets lost in the grand sweep of the arguments, and they often include errors or oversights.

But it’s also a question about the purpose of these discussions (and these kinds of books).  Courtwright is writing because he’s concerned about trends in behaviour, and the economic and political forces that are moulding these.  The book ends for a call for us to avoid ‘excess’, both in enjoying pleasures and in our politics.  (I’m sure some members of the Drinking Studies Network would have plenty to say on this.)

Maybe it’s my personal baggage, but it all feels a bit ‘centrist dad’, like a cry for us to grow up and become ‘rational’ adults.  I felt like I was being told to drink less, go to bed earlier, and probably vote Lib Dem.

The thing is, that isn’t necessarily ‘rational’ for everyone.  One person’s pleasure is another’s vice.  The key question is how to define and police the boundaries between these categories of pleasure/vice/addiction.  Can we?  Should we?

If this is a call for a return to classical liberalism, we can’t be sure how we should regulate pleasure.  A reliance on single word like ‘excess’ cannot resolve the fundamental tensions in liberal thought, even if we could all agree to call ourselves ‘liberals’.  Think of TH Green and JS Mill arguing in the nineteenth century about what the truly liberal position on alcohol was.  When, where and how can lines be drawn defining competence, capacity, freedom and harm?  You might think I drink too much, but who can genuinely judge that apart from me?  What if I know the risks and I think what you might consider ‘excessive’ is actually perfectly balanced?

This might sound a bit abstract and overblown, but I want to illustrate that these are real, live and important issues for practice and policy at the moment.

First, let’s look at some of the things Courtwright seems to define as vices.  For example, he seems to worry about young people having no-strings-attached sex in the gap between high school and college (p.203), which, in itself, I can see little problem with.  The devil is, of course, in the detail of safety and consent – but that’s more complicated than condemning this kind of experience in itself.

Oddly he worries: ‘Me-not-them remains a popular game.  Try vaping instead of smoking.  Try cannabis for pain instead of opioids … Disney lobbied to keep casinos from competing for tourist dollars in its Florida backyard.  Yet it hired sommeliers to recommend wines in its restaurants’ (p.231).  None of these particularly worries me.  They sound like reasonable, pragmatic approaches that could well lead to more positive outcomes.  I’m not unquestioningly in favour, but I’d need a bit more persuasion from Courtwright to understand why each of them is a bad idea.

Courtwright even seems to suggest that banning e-cigarettes can be considered an ‘achievement’; a statement that itself would worry many public health professionals, let alone liberals.

Behind each of these statements are fundamental questions about what ‘the good life’ looks like.  Courtwright, for example, praises ‘mercantile and industrial capitalism’ for fostering ‘self-discipline, future orientation, and efficient time management’ (p.210) as if these are all unquestionable virtues.  As if they don’t exist on the same kind of spectrum as pleasure/vice/addiction.  Surely not all those writing during the industrial revolution would have agreed with the claim that ‘Innovation and competition, however fair and orderly, tend to make the social consequences of improved production worse, not better’ (p.226).

He therefore also seems to dodge the implicit question about the ethics of ‘nudging’ people into different behaviours, uncritically noting that certain environments ‘work for us instead of against us’ (p.228).  Who decides what’s ‘for’ us and what’s ‘against’?  How?

At root, we have a view that emphasises the value of rationality.  But there are two key problems with that.  First, there is no single definition of a ‘rational’ decision.  For example, Courtwright states that when Zadie Smith gave up Facebook to help her concentrate on writing a novel ‘She was wise to do so’ (p.209).  Perhaps, but how can we know?  And would we all be wise to do so?  There are plenty of people who have been inspired or supported by Facebook; even supported to give up their ‘addictions’.  How can we develop a general policy position on a medium like Facebook?

Second, constant rationality is not always productive – either for individuals or societies.  There is a reason that feasts and holidays were endorsed by rulers and ruled alike.

Is it that ‘vices’ hold real risks, or are they somehow imagined?  It seems to me that ‘self-control’ is valued not because the consequences of uncontrolled behaviour are risky, but simply because they are (in some people’s eyes at least) somehow irrational.  Well indeed, that is precisely the point.

Perhaps it could be argued that so long as not too much harm is involved, then activities could still be classed as ‘pleasures’ (or perhaps ‘vices’) rather than ‘addictions’.  And yet if they are not rational, how can they still be classified in this way?  How can we then draw appropriate lines between them?

If this still sounds like an abstract and indulgent academic argument, think of how we regulate e-cigarettes, the night-time economy or alcohol more broadly.  If vaping is somehow seen as a vice, not to be encouraged, this has serious implications for public health and smoking cessation  policy.

If we are not able to define clearer boundaries between ‘vice’ and ‘addiction’, then we will struggle to support people who have issues with heavy drinking.  As health professionals wrestle with the issue of why such a small percentage of people who drink heavily access support, there are plenty of people suggesting that we need a more nuanced approach to ideas of mental capacity and consent, arguing that, at a certain stage, we can define heavy drinkers as acting so irrationally against their best interests that they cannot sensibly be said to have mental capacity to make informed, rational decisions about their own welfare.

Without clearer thinking and writing, we won’t get closer to resolving these questions and developing policy solutions.  David Courtwright has offered an interesting and engaging contribution to the discussion, but for me he raised more questions than he answered.

Has substance misuse treatment been moved out of the NHS?

I’ve been struck recently by the number of articles and comments lamenting the state of substance misuse treatment in the UK (and England specifically), and the fact that some of the problems and solutions identified seem to be missing the point.

Two of the clearest pieces have actually been written by the same person, Julia Sinclair, for two different outlets – the BMJ Online and Mental Health Today.  It’s not exactly a torrent of articles, and although this post is a bit of a rant, I should be clear that it’s not aimed at Julia; I have a lot of time for her critique of the state we’re in.  It’s more that her comments have stirred up some frustrations I have with the wider debate about the commissioning and provision of substance misuse treatment services.  You’ll need to judge whether I’m missing the point myself!

Fundamentally, the argument runs that people who use drugs are getting a poor service from treatment, and this is due not only to budget cuts but also the separation of mental health services from substance misuse, which is the result of local authority commissioning which has taken substance misuse treatment out of the NHS.

First off, I want to acknowledge that I actually agree with a lot of the substance of this critique.  Budgets have been cut substantially, treatment is often not as accessible as it should be, provision of opioid substitution treatment isn’t always delivered in line with guidelines, and links with mental health support can be poor.  And I don’t want to enter into an argument about whether the NHS or third sector organisations are good or bad.  Or whether substance misuse commissioning would be somehow ‘safer’ in the NHS.  That’s been well covered before (see here and here).

My point is simply that if we are going to try to improve services, then we need to be able to diagnose the problem accurately, and that means learning from the past, rather than idealising and misunderstanding the arrangements that were in place.  As I often argue on this blog, I think this is less about structures (where budgets sit, which organisation commissions, which organisation provides) and more about getting the right people doing the right work.  That’s the hard bit.  It’s pretty straightforward (and even neat, logical and rewarding) to run a procurement process or take a position on a grand policy issue, but it’s harder to actually ensure that staff are getting appropriate clinical supervision and engaging in reflective practice, for example.

So what about that history?  What is it and why does it matter?

Well, the narrative from the articles (and plenty of other people I encounter in person, from politicians to frontline practitioners) is that before 2013 and the public health reforms, we lived in a world where there was a budget held by the NHS, which was used to fund NHS organisations to deliver high-quality, well-integrated substance misuse and mental health care.

I don’t want to speak for every person, organisation or area, so I’ll just focus on my own experience.  None of these points is accurate.

Prior to 2013, in Dorset, Bournemouth and Poole we had one PCT (though only recently – there had been several in the recent past, all with different approaches to substance misuse which persisted).  This did indeed fund the local community health trust to deliver various bits of substance misuse treatment – an inpatient detox unit in the east of the county, prescribing teams and shared care nurses, as well as funding shared care arrangements with GPs who wanted to be involved (which was a bit hit and miss).  The provision available, though, wasn’t just about the ‘substance misuse’ commissioning; in the west, where there was no inpatient unit, we had use of mental health beds for detoxes, though of course the input to that wasn’t quite the same.  (We lost the use of those beds while the same trust provided both mental health and substance misuse services.  Cuts to mental health budgets drove that, independent of commissioning responsibilities or budgets in substance misuse.)

But this NHS work wasn’t the only provision locally.  And crucially the funding for that NHS provision had nothing to do with the ‘pooled treatment budget’ (PTB) handed out by the National Treatment Agency.  Neither did the social work input to those teams, provided directly by the local authorities.  Neither did the housing provision or ‘supporting people’ work sometimes provided by organisations that also delivered substance misuse support.

Setting aside data concerns, the NTA was part of the story through the three Drug and Alcohol Action Teams (DAATs) locally that were hosted by the three local authorities.  These commissioned various organisations (incidentally all third sector) to provide things like harm reduction, group work, criminal justice interventions (DIP), and aftercare.

So we were doing local authority commissioning of the third sector well before 2013.  In fact, when people talk about ‘the sector’, they’re generally talking about that era of 2001-2013 when there was increasing funding available – and organisations like CRI (as was), Turning Point and Addaction grew dramatically.  Not the NHS.

(If you’re interested in the history of the third sector in providing substance misuse treatment, it’s worth looking at the work of Alex Mold, particularly this article.  There’s a long history that doesn’t start in 2013 or even 2001.  And the NTA’s successor, PHE, has actually written a good history of drug use and treatment in England – see chapter 1 here.)

This patchwork provision, I’m afraid to say, was not seamless and certainly not flawless.  And the issues weren’t simply with the third sector communicating with the NHS.  Even within the same organisation there were issues with ensuring people received the right care, at the right time, in a coordinated way.  Having had discussions with mental health professionals in the last couple of years about how we can improve links between the two services (now provided by different organisations), I have heard some world-weary complaints about how ‘we’ve been talking about this for 20 years or more, and nothing ever changes’.  So much for this being better when it was ‘all in the NHS’.

It was crap in 1982 and its still crap now. All you hear is people at conferences saying how the two need to work together. More like 40 years than 20, certainly more than 6.

— John Divney (@JohnDivney) August 21, 2019

And in fact it is still, as much as it ever was, in the NHS.  The prescribing services may no longer be provided by GPs or the local community health trust, but they are provided by another NHS trust – in fact, one with a specialism in mental health.

But I’m overplaying the position taken in those particular articles.  Julia calls for a ‘return to joint NHS and local authority commissioning of addiction services’; it’s just the blunt phrase ‘addiction services were moved out of the NHS into local authorities in 2013’ that gets my back up, as this suggests that everything went wrong when things moved out of the NHS – only most things weren’t in the NHS anyway, and those that were are still often delivered by the NHS.

We have some structures for joint commissioning still, but I’d accept those could be more proactive in driving genuinely joined up work.  But equally let’s not kid ourselves that DAATs were some ideal world.  My experience was that they were seen as a decision-making body for the local authority element (and we were generally able to get committee agreement for our proposals), while the NHS (PCT) saw itself as being bound by its own processes, not the DAAT Board.

For me, the issue isn’t that addiction services have been taken out of the NHS.  When Julia worries that ‘addiction services are now often disconnected from wider health and care services’ we’re more in agreement.  That word ‘care’ us crucial here, and highlights that the fundamental issue isn’t about organisational boundaries and responsibilities.  Despite nominally being part of local authorities, my experience is that public health commissioning and social work provision are more separated than they were before 2013.  We’ve lost those embedded social workers (though particularly in Dorset Council some of those staff are doing different, but extremely valuable work related to substance use).

The loss of those embedded social workers, just like the loss of the mental health beds, isn’t down to commissioning responsibilities.  How could it be if hosting commissioning in one organisation is a solution?  It’s all part of the local authority…

In reality, it’s down to all organisations being squeezed and choosing, as a result, to focus on ‘core business’.  And substance use isn’t seen as core business by anyone but public health teams (and even then it’s questionable).  Don’t imagine it was seen as ‘core business’ and the budget didn’t get raided before 2013.

The challenge isn’t where these responsibilities sit; it’s getting the right people to talk to each other, in the right way, at the right time.  As we all know, that can just as hard within a single organisation as across them.  Sometimes it’s actually easier across organisations because people aren’t competing or jockeying for position.  But that, like all of this, depends on circumstances.  Let’s not imagine we can find a solution in structures.

Why secondhand drinking isn't like secondhand smoke

This week the Guardian have published a piece highlighting the indirect harms that can arise from drinking.  This is important stuff that should be more prominent in alcohol policy debates.  Too often, issues around alcohol policy drift into the classic libertarian territory of saying that it’s simply someone’s individual choice what they put into their body.

This position neglects two key points.  First, decisions are made in specific contexts that have been designed, consciously or not, by policy.

Second, our decisions have impacts on other people; no man is an island.  The classical liberal debates about alcohol aren’t simply about whether alcohol enslaves the individual drinker, as JS Mill put it, but also in terms of his ‘harm principle’: do your actions harm those around you?

The article in the Guardian lays out quite clearly some potential harms from other people’s drinking: violence, drink driving, neglect, abuse, and so on.  And Ian Gilmore makes what seems an obvious comparison with passive smoking.  Indeed it’s referred to as ‘secondhand smoke’, and the title of the article refers to secondhand drinking.  We’ve been here before.  In 2009 Liam Donaldson referred to ‘passive drinking’, though the concept didn’t get much traction.

I should be clear that I think discussing these very real and serious harms is important, and can – indeed should – reshape our debates about alcohol policy.  However, this analogy worries me, for all the usual reasons I write about on this blog.  We need clarity and honesty from messengers on this issue for two reasons.  First, you want to protect your reputation as a messenger for being open and truthful.  Second, and much more importantly, you actually want to generate the best policy solutions, which means being clear about what exactly the problem is.

For ‘passive’ or ‘secondhand’ drinking, the problem is qualitatively different from ‘passive’ or ‘secondhand’ smoke.  If we base our solutions for alcohol simply on analogy with tobacco, we’ll make some serious mistakes, as they’re quite different drugs, perceived quite differently, that play different roles in our society.

Crucially, the danger with passive smoking is in the substance itself: someone else is exposed to the toxins in the smoke.  This is the key justification for the smoking ban: you physically need to separate non-smokers from smoke to reduce their risk of developing certain health issues.

For alcohol, this does not happen.  A child might access a parent’s alcohol, for example, but this is not ‘passive drinking’; it’s actual drinking.  The harm comes not directly from the substance, but indirectly through the person using it.

As the Guardian piece points out, there are all sorts of harms that are related to alcohol.  However, these are quite different to those related to tobacco.  People in smoking areas tend not to start fights after they’ve had just a few cigarettes.  People tend not to fail to get the children to school because they’ve been busy smoking too many cigars the night before.  You don’t have a few pipes of tobacco and become incapable of driving safely.

To be fair, I think Ian Gilmore knows this.  He explains that the smoking ban, which he sees as a positive policy intervention, was only possible as a result of increasing awareness amongst policymakers and the public that secondhand smoke is bad for your health.  But he then recommends a completely different policy solution for ‘secondhand drinking’: increasing duty, and therefore the price.  This is genuinely analogous to tobacco – but analogous to an intervention introduced to reduce harm to the smoker, not those around them.  The idea is that higher taxes both reduce consumption and enable society to pay for the treatment of health conditions of those who do continue to smoke (though the cost-benefit analysis of the latter point is much debated).

What Gilmore is really doing is being disingenuous, or more generously being a pragmatic lobbyist.  He states: “Secondhand smoking [as a concept] really changed public opinion and paved the way for legislation to make bars and public places smoke-free.”  Here he is stating his lobbying approach.  He wants to establish secondhand drinking as a concept in public opinion so that different policy solutions are contemplated.

And this is fine by me.  If we define the problem differently (it’s not just about harm to the individual drinker, but the people around them too) then it’s reasonable we should consider different policies to address this.

The problem is that tobacco is a poor comparison because of what causes problems and what it’s place in society is.  And in pragmatic terms this is important not just because we want to have accurate descriptions of reality, but because lobbyists want to use the right tactics.

But for the moment let’s just focus on the reality.  Most of the problems with tobacco are about tobacco.  If you replace the tobacco smoke with other ways of getting the actual drug – nicotine – then suddenly much of the harm (to others as well as the person using) disperses too.  When we’re talking about bans on e-cigs, we’re in the slightly trickier territory of JS Mill’s use of the word ‘nuisance’ rather than his clearer idea of ‘harm’.

As I wrote last week, many of the problems related to alcohol are not neatly about alcohol.  We can take the substance away and still not resolve the underlying issues.  A reductive focus simply on price and availability will not serve those who still end up drinking – and those around them.  When we discuss the harm of ‘secondhand drinking’ we need to be thinking about treatment, culture, education, social support, wider resources.  I worry that the analogy with tobacco leads people to a narrow set of ‘solutions’.  Gilmore states: “[With cigarettes] we have relentlessly pushed the price up.  Quietly, but relentlessly.  And that’s made a huge impact.  The UK is the leading European country in reducing smoking rates.”  The analogy remains and the conversation comes back to price.

‘Passive drinking’ never caught on as a concept.  Maybe ‘secondhand drinking’ will, but it needs to mean something more than an analogy with smoking, otherwise the public and policymakers will, quite rightly, see through it.  We can do better than this.  Let’s be open and honest about this issue (as most of the Guardian piece is), and work from that to realistic, sensible policy interventions.

There but for the grace of God

Over the past few weeks, and in my previous blog post, I’ve been debating how we can best think about the support our sector tries to offer.  Sometimes this is about structures of oversight and how different services are divided up, but I’m frequently reminded of the possibly trickier issues of funding and stigma.  In this post I want to suggest they’re all potentially linked.

As I say, I’ve been thinking about targeted support and stigma a lot recently.  It’s the old issue of how you can offer targeted support to those who need it most, without creating a perception of them somehow being less than ‘normal’ people – a perception that will quite possibly make people less likely to seek out that support, as doing so would identify them as ‘in need’ or ‘at risk’.

This is a standard social policy issue, applied to school meals, university fees, child benefit, and so on.  In general terms, the argument would be that since the 1980s we have seen a move away from these approaches to something more targeted.

While there are potentially issues with this ‘targeting’ approach, the logic makes sense, and to a certain extent it’s unavoidable.  If we have limited resources, we have to ask how we can prioritise different issues or individuals.  This might seem to have become more severe during a period of austerity, but it’s not an issue that goes away: if we get an increase in funding, there will always be more worthy causes and good ideas than it can support.

But I’ve been conflating two ideas here: targeting issues and targeting people.

We will always have to balance up different initiatives or issues.  For example, are we more concerned about TB or measles as infectious diseases at the moment?

Think of this as comparable to when you move house.  You might well debate whether to redo the bathroom or kitchen first – or perhaps at the time it’s more of a priority to repaint a few other rooms.  Most of us don’t have the time or money to do everything at once.

That happens in all departments and policy areas.  We live in a finite world.

So why am I worried about stigma?

Well, targeting issues is not the same as targeting people.  (And even targeting issues can cause stigma if we see those issues as only relating to certain people.)

Let’s compare the attitude to prevention for measles and cervical cancer.  Both are prevented through vaccination, and there have been issues with ensuring coverage of both – but for quite different reasons, I would suggest.  The MMR scare has been well-documented.  The issue there is seen as being in the vaccination itself.  Some people perceive it as risky.

The issue with the HPV vaccine (though it doesn’t seem to be talked about much anymore) was that this was a sexually transmitted virus and so there was some concern that admitting to needing it was an acknowledgement that you, or perhaps more accurately your daughters, were likely to have unprotected sex.

The framing of this as a population issue helped get us over this: the vaccination is just something that health professionals recommend for everyone, to reduce our risk at a population level.  This is framed as leading to ‘community immunity’ as some people call it (to avoid thinking of people as a ‘herd’).

So what’s this got to do with alcohol?  Well this is again that old issue of whether ‘the problem’ resides in the substance (alcohol is ‘no ordinary commodity’ – a carcinogen, a toxin or a poison) or the person (‘I am an alcoholic’).  I’ve written about this before, and my usual get-out is that there are as many problems related to alcohol as there are individuals experiencing them.  We therefore shouldn’t search for a single diagnosis or solution.

But this doesn’t really help policymaking in lots of contexts.  Saying ‘it’s complicated’ (or more likely in policymaking circles ‘complex’, ‘multifactorial’ or ‘wicked’) doesn’t get us very far.  What are we going to actually do about that complexity?  (Actions speak louder than words.  You talk, we die.)

This is particularly acute when we know that, even controlling for the total amount of alcohol consumed, different groups of people experience different levels of harm.  This is partly due to certain protective factors and differences in patterns of consumption, but it’s also because risks don’t seem to just add together, they multiply.  Drinking and smoking and low levels of physical activity combine to make a particularly toxic combination for a range of health risks.

I say ‘different’ groups of people.  I mean class.  People from more deprived areas face higher levels of alcohol-related health harm even though, on average, they’re drinking less.

What can we do about this?  And what can we do about the fact that dependent drinkers are not a particularly popular group, and people find it hard to say ‘there but for the grace of God go I’?  Is this difficulty in identifying with ‘alcoholics’ partly due to the Alcoholics Anonymous approach of defining ‘alcoholics’ as a distinct, tightly defined group of people?  If we want public support for treatment or prevention, we need people to identify with those facing issues – unless we want to resort to the ‘mad, bad and dangerous to know’ approach that justified funding drug treatment in the 2000s.

Kettil Bruun and others solved this by suggesting that interventions should address a whole population (the HPV and measles approach), whereas Michael Marmot, thinking about wider public health issues, proposed something called ‘proportionate universalism’ in an attempt to square the circle: support is universally available, but targeted and made accessible for those most in need or traditionally least likely to make use of it.  Both represent a response based on the understanding that we live in a class society, which shapes both material resources and status.

So what does this mean for us today?  What are the burning issues in alcohol policy where this is relevant?

Well I’ve been thinking recently about two popular ideas.  One is labelling of alcoholic drinks, and the other is their idea of improving funding for alcohol treatment – perhaps through a ‘treatment levy’ as Alcohol Change have suggested: a specific addition to alcohol duty that is ringfenced to support alcohol treatment in the UK, which is still in some senses the ‘poor relation’ of drug treatment, which is not exactly affluent itself.

I think these two approaches (albeit slightly tweaked) have much in common, and can provide the best of the Marmot and Bruun approaches – which in themselves are attempts to get round that knowledge that, yes, alcohol is a potentially problematic substance for all, but perhaps we’re not all equally at risk.

Labelling is not simply about individual level decision-making on a specific occasion.  If we model it in that way, there’s a danger that (thinking about calories, for example) someone might choose to have a few vodkas rather than just one glass of wine, and end up drinking more alcohol.  For me, the point is more to create that general perception that for everyone alcohol is no ordinary commodity, and has risks attached.  That can then shape decision-making and culture in the longer term, both at an individual and population level.

I don’t want to overstate the potential of this.  More fundamentally you could ask the question why this information is displayed on other drinks but not ones containing alcohol.  But there is a neat dovetailing with the need for funding for alcohol treatment.

This levy is designed to specifically improve alcohol treatment, which supports people with the most serious problems but perhaps doesn’t do as much as we might hope.  In England, treatment services engage more than 50% of all people estimated to be using heroin, whereas they manage about 15% of people drinking dependently, which itself is a narrow definition of having a problem.

Specialist treatment, then, is focused on those most in need.  And here we return to the example of HPV.  If we think of the treatment of cervical (or other) cancers, debate tends not to focus on the fact that many of them are linked to ‘lifestyle’ factors such as smoking, drinking, diet, exercise, sexual behaviour (in terms of virus transmission).  Cancer is seen as a lottery and people should be treated.  Alcohol dependency is not viewed in the same way.  As in the HPV example specifically, it was seen as being linked to individual personal choices.

And this is where the idea of an alcohol levy, though logical, has some challenges.  It is an addition to alcohol duty, designed to support services that only serve a minority of the population.  I think that, rather than a levy, a more achievable idea is a broader ‘rationalisation’ of alcohol duty.  There is some appetite for this – and from organisations like the IFS, not just alcohol specialists.  From a political perspective, as I’ve noted elsewhere, there’s an opportunity to frame this kind of change as a positive of Brexit; something that I imagine politicians will be keen on (if this ever goes ahead).

The other advantage of this framing is that it feels less like a targeted tax all drinkers pay for people who have problems they don’t.  Of course this is the basic principle behind taxation and public services, but that doesn’t mean it’s an easy sell when this discussion is only about a particularly challenging issue.  If this allocation is contained within broader alcohol taxation (and I still support the idea of a hypothecated tax to produce a ringfenced budget) then that debate about the principle of ‘who pays’ is less at the forefront.  This is potentially a virtuous (or vicious) circle.  If we believe general taxation is for issues that affect us all, and alcohol treatment is funded in this way, then perhaps we might start to see alcohol treatment less as something that is for a special category of people.

And this links with the idea of labelling, which presents alcohol as a substance that comes with certain risks.

Crucially, though, this is different from the total consumption / whole population model of alcohol harm.  It acknowledges that alcohol is not all about risks adding up and leading to harmful health conditions, or even the slightly more subtle point that if we all drink more at a population level there will be more dependent drinkers.

The point is that there is, to some extent, a special category of people who are facing bigger challenges than the rest of us.  Their issues aren’t simply hangovers, ‘presenteeism’ at work and failing to fulfil some imagined potential.  But also, as with most other health or social issues, we can’t perfectly predict who they will be.  The point is to generate not just sympathy but empathy for those who need treatment.  ‘There but for the grace of God…’

Local substance misuse services or national everything services

Whether it’s in relation to alcohol or opioid treatment, I’ve been thinking a lot recently about how people might need support specifically in relation to certain substances (as opposed to ‘substance use disorders’ or wider issues related to health or social care).  That sounds a bit cryptic, so let me try to explain.

As usual with this blog, it’s not an original or mind-blowing insight, but something that keeps occurring to me that I think we should remind ourselves of more often.

When we discuss treatment or policy, we often do this by substance.  So there’s been discussions of alcohol labelling recently, and a growth in personal testimonies of how giving up alcohol makes people fitter, happier and more productive (recently Megan Montague’s Sober Story caught my eye).  And there’s discussions locally and nationally of how we can specifically improve opioid substitution treatment (OST).

But as we know, if ‘addiction’ is anything, it’s about more than a substance.  It’s about all those things we label ‘recovery capital’ – health, housing, employment, relationships, etc – whether for good or bad.  To a certain extent, substance use becomes a ‘substance use disorder’ when it starts to have negative effects on other aspects of a person’s life.

And so it’s unsurprising that people find it hardest to change their patterns of substance use when the challenges they’re facing – and their reasons for using – are not just about the substance.  It’s people with the least severe issues for whom the substance is the primary problem, and it’s these people who are best served by interventions that focus on the substance itself – like alcohol brief interventions.

And yet when we talk about treatment services, we’re generally thinking of things that are designed for those most in need of support.  We know that most people ‘spontaneously recover’ without formal support, as a result of their own thinking and support from friends, family and the wider community.

And yet the services we provide – which should be replicating those supporting factors like employment, housing, family, community – are typically labelled ‘drug’ and/or ‘alcohol’ treatment services.  In fact it’s not just that they’re labelled in this way; we commission and provide them separately from housing, employment, and other health and social care services.

This doesn’t make sense to me.  And in conversations and meetings over the past few months and years I’m encouraged by the fact it doesn’t seem to make sense to anyone.  I’ve written before about how substance misuse treatment can feel neither part of the ‘health family’ or social care and other related services, and given the cross-cutting nature of these issues there’s no point in searching for the ideal institutional ‘home’ for this agenda.  But equally, it’s inefficient (and exhausting) for local areas to be reinventing the wheel, and I think there are some structural and policy changes that could make this easier.

This doesn’t just mean devolution of budgets, though that might make collaborative work easier.  I still don’t think there’s a magical solution, and the key is to get relevant people to work together better at a local level – not just on the frontline, but in linking policies and planning.

This isn’t an endorsement of localism, though.  Without some form of external prompt, when we’re under pressure we often have a default of ‘tending our own garden’.  It can seem not just comforting but a priority to focus on what we can control ourselves and JFDI if we want to make a genuine difference.

The problem is that this isn’t the most efficient way to deliver support to the people we’re most concerned about.  There is a role for national organisations like PHE to be that voice reminding us to look up and think about the bigger picture.  Actually, it needs more than just a voice.  Recommendations are often disregarded, or considered to be stating the obvious – even if they’re equally obviously unachievable.  Requirements, from an agency with teeth, can drive these conversations, particularly in the areas where collaboration is most challenging.

In searching back through this blog to see when I’ve written about this before, I notice a striking, brief piece from several years ago.  Nothing has changed as yet, but the sheer weight of reports and recommendations from organisations like the ACMD do genuinely seem to be making a difference.  More and more people seem to be agreeing with the idea that strengthening national guidance and oversight (even commissioning at a national level) would be a step forward, and I get the feeling that key people with influence at a national level are taking this on board.  Here’s hoping.

Can we build a more trusting, collaborative substance misuse treatment sector?

I spent Friday in Manchester, at EXCO2019 – the annual conference of the Expert Faculty on Commissioning.  There were lots of fascinating discussions throughout the day, and I’d recommend catching up by looking at the hashtag on Twitter: #EXCO2019.

One of the key issues revolved around balancing ‘dusting off the old vinyl’ and doing the basics well on the one hand, with the bright shiny disco ball of ‘innovation’ on the other.  Pete Burkinshaw from PHE kicked us off with this metaphor, but pretty much everyone else used it thereafter – in fact Kate Hall had already independently written it into her presentation!

As Tony Mercer from PHE suggested (echoed by Paul Musgrave later, who hadn’t heard Tony), we might sit down at home and listen to vinyl, but it doesn’t work everywhere: you might play CDs in your car and listen to MP3s on the train.

And this was the other key theme of the conference: tailored, or personalised treatment.  There’s an idea that I’ve written about before that although we hope tailored, segmented, personalised treatment will be efficient as well as effective and fair, but we shouldn’t take this for granted.  Fordism, where every colour is available so long as it’s black, sometimes has its place.  The devil, as ever, is in the detail, and the risk with this conference (as with most others) is that it becomes a sequence of platitudes, soundbites and metaphors without taking us forward in practice.

There was much discussion of ‘optimal’ dosing, defined as 60mls-120mls of methadone per day, or equivalent.  But Kerrie Hudson had earlier noted that, for her, being able to deal with cravings in the morning with a relatively low dose of methadone (say 30mls) and then use at other times, was a stabilising factor, meaning she could carry on working.  It was appropriate for her particular situation at that particular time.

The sensible way through this is to point out that (a) the patterns of prescribing in our system don’t suggest that most people on 30mls are ‘optimised’ even by their own definition, and the actual dosage of medication someone receives shouldn’t be imposed (whether that’s through an increase or reduction); it should be a joint decision between clinician and patient to achieve a jointly agreed aim.

And that kind of approach, along with all sorts of other initiatives that could be badged as ‘innovative’ or involving ‘segmentation’ were discussed on the day.  But they remain that: isolated examples of good practice.  We don’t (yet) have a tool for segmentation that could structure these kinds of conversations that keyworkers need to have.

In the session I participated in, I had been asked to introduce a discussion of depot buprenorphine – a fact possibly not unrelated to the fact the conference was made possible by funding from Camurus, who make these devices.

I don’t object to this, though the Faculty needs to be careful not to become reliant on one source of funding, and I think local authority contributions would be more appropriate.  I saw my role as being to ask some challenging questions and bring the conversation back to those practical considerations, rather than thinking the innovation will be useful in itself.  Who will this form of medication benefit?  Where could it be implemented effectively and efficiently, given we’re living in tough times financially?

I’m not sure I got my point across, but it didn’t matter anyway, because the discussion, thanks to much more eloquent and passionate commissioners than me, took a turn to be about commissioning and the ‘sector’ in general.

This was where the conversation got interesting.  We talked about how certain metrics and processes, previously centrally imposed (like TOPs and ‘successful completions’) don’t have to be at the heart of local authority commissioning, but the point was made that this doesn’t mean agencies and staff can disregard them even if they wanted to.

As a provider, you can’t be sure that if your successful completions are low in one area because you’re being honest and retaining people in treatment, that you won’t be judged unfavourably when you tender for a contract in another area.  Not all commissioners take this view.

And as a member of staff, if you stop recording people (sometimes optimistically) as successfully completed, or don’t note that they have apparently stopped using on top or committing crime on their latest TOP form, then perhaps you’ll lose a sense of a job well done.  And how will the service user themselves be able to identify that they’re making progress?

It’s not as straightforward as a commissioner just telling a provider to relax about metrics.

And what about length of contracts?  There was agreement that long contracts were a good idea, and local authorities seem to be increasingly open to these.  But it’s not the case everywhere, and the sector still feels competitive.

Nurses leave to work elsewhere in the NHS because there just isn’t (felt to be) the same security in substance misuse.  Locally, in each of the three acute hospitals across Dorset there’s at least one nurse in the alcohol liaison/care team that used to work in the Dorset substance misuse service, and we can’t seem to recruit replacements.

Organisations feel they can’t reveal their ‘trade secrets’ (and if anyone has indeed got the ‘solution’ to ‘addiction’ there certainly keeping it secret), and the spectre of tendering can lead to tensions, fear and anger on the ground.  It’s hard to believe that doesn’t then seep into consultations, affecting service user care.

And this isn’t the fault of those frontline staff or the organisations that employ them.  It’s central and local government that have created and maintained these competitive structures.  And while some people in the room could be congratulated on creating different approaches in their area, this doesn’t change the overall picture or culture as being one of competition and sometimes open confrontation.

So I started to think about how, in practice we could make this change.  And all the themes we’d been discussing seemed to coalesce.  We don’t have clear segmentation tools.  Guidance on ‘good practice’ tends to be relatively abstract (NICE, Orange Book) or just a set of examples designed to show that local government is brilliant (the Local Government Association).  Approaches to performance management vary considerably.  Contract lengths vary wildly from 3 years to 10 or more.

This lack of consistency makes life difficult for providers, who can’t tailor their approach to one commissioner, and commissioners, who end up reinventing the wheel.

Last year, I wrote about how I could see a role for the Expert Faculty as a repository for genuine, practical examples of ‘good practice’, but this would need to be distinct from the work of PHE or the LGA.  Some of the work that could improve the situation is being coordinated by PHE through their review of opiate substitution treatment, which I’m hoping will produce some practical guidance on segmentation, enabling frontline workers to put the ‘phasing and layering’ of treatment proposed by the Medications in Recovery report into real-life practice in a straightforward way.

But there’s more that needs to be done to reshape the sector and build trust.  One thing I wondered aloud about in the session of the conference I was directly involved in was something like a charter or a kitemark for commissioning.

Providers want to feel confident they’re entering into an arrangement with someone who’s reasonable, flexible and constructive, and where they don’t have to worry about misleading metrics.

And commissioners, I’m sure, would embrace a set of principles – particularly if they could take these to elected members or senior management and explain that these (for example not re-procuring every 3 years) are considered good (or even standard) practice in the field.

I’m not going to talk much more about this here, as it’s only the most embryonic of ideas (and I wouldn’t claim that it’s original) but I wonder if it’s worth exploring further.  It would surely give both commissioners and providers the confidence to break free from the shackles of successful completion metrics and 3-year tendering cycles that occupied so much time and prompted so many sighs over the course of the day.

I often ask for comments on this blog, and rarely get any, despite hundreds of people reading it, supposedly, so I’m not expecting a great debate in the comments.  What I hope, though, is that by EXCO2020 we’ll have a clearer sense of the practical, tangible contribution of the Faculty, and whether this sort of initiative is what it should be championing.

Consultations on drug policy

A couple of days ago, I was asked by email for some comments on the current health and social care select committee (HSCC) inquiry and Black report consultations on drug policy.  Tonight, on my own time, I drafted some thoughts.  I've copied these below and would welcome comments.

Just to give some context, the questions in the Black report at this point are as follows:

·       What are the demographics and characteristics of drug users and drug suppliers and how have they changed?

·       What causes individuals to become involved in drug use and/or drug supply?

·       What are the evidence-based approaches to preventing and reducing drug use and drug supply?

·       What causes drug related serious violence and how can it be prevented?

·       What are the most important evidence gaps relating to drug use and drug supply and what further work would be needed to address them?

And those for the HSCC inquiry are:

Health and harms:   

• What is the extent of health harms resulting from drug use?  

Prevention and early intervention:   

• What are the reasons for both the initial and the continued, sustained use of drugs? This refers to the wide spectrum of use, from high-risk use to the normalisation of recreational use. 
• How effective and evidence-based are strategies for prevention and early intervention in managing and countering the drivers of use? This includes whether a whole-system approach is taken. 

Treatment and harm reduction:  

• How effective and evidence-based is treatment provision? This refers to both healthcare services and wider agencies, and the extent to which joined-up care pathways operate. 
• Is policy is sufficiently geared towards treatment? This includes the extent to which health is prioritised, in the context of the Government’s criminal justice-led approach.  

Best practice: 

• What would a high-quality, evidence-based response to drugs look like? 
• What responses to drugs internationally stand out as particularly innovative and / or relevant, and what evidence is there of impact in these cases? 

If you want to respond yourself - and I think this is something everyone with an interest should get involved in - the HSCC consultation closes on Monday.

So here goes my response.  I should point out it's not a formal response; just some thoughts that have occurred to me over a glass of my favourite intoxicant.

****

Having read through this, I think the fundamental questions are relatively similar, so here’s my stream of consciousness, which reflects the views of an academic rather than a commissioner.

Most drugs in themselves carry relatively low risk to the individual concerned when used in known dosages and purity, under safe conditions without forming patterns of substance use disorders.  Therefore the health harms resulting from drug use per se are relatively low.  Issues are most likely to arise when purity and dosage are unknown and where people have poor information about how to use more safely (or do not act on this information, sometimes due to the stigma or fear associated with the illegality of certain substances).

People come to use drugs initially due to a mixture of factors, with (anticipated) pleasure of some kind linked to availability.  What people find exciting, comfortable or pleasurable varies, and the effects of different drugs varies and is affected by setting, and so the reasons are as varied as people who use drugs themselves.  In understanding why people continue to use drugs, a functional approach is helpful: these substances serve a function for the people who use them, whether that is to have new experiences (‘psychonauts’), distance oneself from previous experiences or thoughts, or simply experience a ‘rush’.

For most people, trauma and poverty / lack of opportunities drive people towards problematic drug use and dealing.  Those involved in dealing are getting younger.  The violence associated with the drug market is the consequence of the substances being illegal, and violence increases when a gap in the market appears – i.e. when existing, stable dealers are arrested and imprisoned.

(But I understand the Black review has been instructed not to consider the legal status of drugs.  And in any case, the police will be more expert than me on this.  I hope Neil Woods from LEAP will be submitting evidence.)

Prevention of pursuit of intoxication and use of psychoactive substances per se is a somewhat futile task.  All societies, to our knowledge, have made some use of intoxicants or intoxicating practices.

Evidence suggests that the most effective approaches to prevent harm from substance use is not to focus on substance use or dispense information and advice, but to educate young people in relation to decision-making and safekeeping strategies, and to discuss these issues with adults in terms of the effects on their wider lives (e.g. improving parenting skills).  Such work should be integrated into broader process/practices, e.g. mainstream education, general healthcare and social work practice.

In terms of treatment, while there is relatively strong evidence that high-quality treatment and harm reduction initiatives can reduce crime and reduce the transmission of blood-borne viruses, there is a lack of evidence regarding ‘what works’ in fostering long-term recovery.  Therefore a priority for government should be to commission and support research that takes a robust, longitudinal approach to evaluate different treatment options and approaches in terms of their effectiveness.

As to whether currently commissioned treatment services are provided in line with this evidence, there are questions to be asked as to whether services engage enough people to make a difference at a population level, and whether, once people are engaged, they receive treatment in line with this evidence, much of which is based on either lab-style settings in terms of talking therapies, or US-style ‘methadone clinics’ in relation to opiate substitution treatment (OST).  What evidence there is suggests that dosages of medication dispensed as part of OST are not generally in line with evidence, supervision regimes are not applied consistently, and talking therapies are not delivered in line with tight guidelines.  In most cases there is certainly not joined up health and social care provision for the client group who have run into issues with substances, with services commissioned and provided by separate organisations, operating to different priorities and policies, and using different IT systems.

This is not to say that services are not appropriate and effective, given the limited nature of the evidence base.

The biggest challenge to delivering quality services is currently capacity.

Treatment services have been more than decimated in recent years, with cuts in most areas of at least 20% to budgets since 2013, and prevention work has become patchy and hard to monitor with the change how schools are overseen.  At the same time, resources expending on addressing the supply of drug use, for example through ‘county lines’, have increased in areas such as Dorset.  This is currently a ‘zero sum game’, and therefore it would appear that resources are being focused at less effective points in people’s lives, given that we know treatment can help reduce the burden problematic drug use and associated acquisitive crime can place on the criminal justice system.

A high-quality, evidence-based response to ‘drugs’ would be regulate all substances and therefore permit use that is in line with good harm reduction advice: i.e. where people can know and control the dosage and purity of the substance, and the manner in which they ingest their preferred intoxicant.  There would be more accessible treatment, better integrated with different elements of the health and social care system, a better evidence base by which to judge the performance of this system, and more resources to support the oversight of the system in relation to quality.

As for international comparisons, no country has this cracked, partly because opportunities for innovation are hampered by international treaties and the position of the UN and particularly the USA.  In general, we know that harm is not simply determined by a country’s regulatory or treatment system, as confirmed by the Home Office report a few years ago.  Each country should take a tailored approach to each substance, based on its history and starting point today.  Social and cultural context play a key role in determining problems and appropriate solutions – just look at trends and approaches to alcohol use in different countries around the world.  An approach that is perfectly reasonable and successful in one context can be destructive in another.  However, to focus on specifics, the approaches adopted by Uruguay and Canada for cannabis seem to me the best models for effective regulation introduced so far, though they will need careful monitoring to evaluate their impact, particularly in comparison with the various alternative regimes in operation across the US.  These initiatives could and should go further, however, and cover all intoxicating substances – though with regimes tailored to the particular risks associated with each drug.

As you’ve probably guessed, I’m writing this on my own time, as it may not be what you were looking for!

Best

Will.

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UPDATE:
This morning I was asked why I hadn't mentioned Portugal, and whether this would be a good idea.

This was my response:

Personally, I think we're not far off the Portugal model in the UK, with treatment offered for most people who commit drug-related acquisitive crime and very few people (in the grand scheme of things) imprisoned for possession. The greatest harms (DRDs, child exploitation, cuckooing) wouldn't be solved by decriminalisation, but only legalisation.

But you're right that it at least reflects an achievable step, and highlighting it could convince people that change is possible.