Drug policy and scientific morality

David Nutt is in the news again, talking about the dangers of alcohol (and incidentally promoting his book).  He was on Radio 5 this morning, I think, but this piece in The Guardian offers a good summary of his current position.

I’ve written before about the idea of single ‘harmful’ scores for individual substances and how I find them unhelpful – not just because they’re simplistic, but because they perpetuate a particular approach to drug regulation that I think is naïve and therefore gets ignored.

But I just want to highlight a particularly odd position David Nutt takes in this article.  He suggests that people should share a pint of beer, as just 5g a day is the ‘optimal’ dose.  This is less than a UK ‘unit’, and works out (apparently), as about 40ml of wine – less than a fifth of a large glass you’d be served in a pub or a restaurant.

Even though it's been suggested focusing on this is misleading, as it's likely to have been a throwaway comment used as an illustration, the article has been endorsed by David Nutt - and more importantly it's a revealing, and inconsistent comment.  But at least it’s consistently inconsistent.

As a campaigner for drug policy reform, David Nutt acknowledges the desire to take ‘drugs’ – indeed he proposes that rather than seeking a world in which people don’t use alcohol, we actively create and regulate an alcohol-like intoxicant that is less harmful, and allow people to use this.

Apart from the fact that this proposed ‘alcosynth’ relies on an assumption that we can create and adopt a genuinely new substance to take the place of something that has been part of society since before we were human, the rationale for trying sounds like pragmatic harm reduction: acknowledge an impulse to get intoxicated, and rather than ignoring it or pretending it can be legislated out of existence, provide a safer way that it can be satisfied.

Yet suggesting an ‘optimal’ dose of 5g doesn’t do this.  This is only ‘optimal’ if you don’t want to be intoxicated.  And here we get to the nub of so much alcohol policy discussion: we bring our own preferences and prejudices.  An ‘optimal’ dose can only be judged by the person using it, even if we know ‘objectively’ its effects, whether in terms of intoxication or harm.  I might value my long-term health less than other people, and I might value intoxication more highly.  In which case 5g isn’t so much an ‘optimal’ dose as distinctly ‘sub-optimal’.

This is a strange position for a drug reformer to take.  The whole basis of David Nutt’s campaign against the current drug laws is that they have imposed some kind of moral, philosophical or political priority (intoxication is bad) rather than listening to ‘objective’ science.  But of course there is no universal, objective cost-benefit analysis of drugs, so the language around ‘optimal’ immediately raises the spectre of one set of personal judgements – those of ‘experts’, speaking as an oracle* – simply replacing another.

Previously, I’ve thought of this ‘rational’ approach to drug reform as simply naïve about not only policymaking, but the reality of social existence.

To summarise, the naivety about policymaking is first that telling politicians they’re behaving irrationally isn’t a great lobbying technique, and second imagining that ‘harm’ is the only thing drug policy could ever be about is misguided.  Not only can we not define ‘harm’ in any practical way that acts as a guide for policymakers, but there are plenty of other (legitimate) influences on policy other than reducing ‘harm’.  Balancing freedom, economy and morality is no mean feat.

And the naivety about social existence is simply that even if we’d like to start from some kind of ‘year zero’ in regards to drug policy, we’re dealing with substances that have a social history.  Whether we like it or not, the fact that alcohol has been legal and available in Britain for thousands of years makes a difference, when it’s compared with the substances that are currently illegal.

But looking at this again, I realise there’s something else that has troubled me about this approach, at a more emotional level.  I’ve been chatting about PSHE this week at work, and a couple of us were reminiscing about how, when we were at school, drugs education consisted of handing out booklets that contained key information on all the major drugs – where they tended to be available, how much they were likely to cost, what the effects were and how long these were likely to last.  Whether you ended up taking them or not, most people looked at that booklet and did a quick cost-benefit analysis to see which would be their preferred drug.  Perhaps not the intended response, but it illustrates a key point for drug policy: we didn’t all agree.

I think my problem, fundamentally, with the Delphi model is that someone else has done this cost-benefit analysis for me, and I don’t agree.  (Or perhaps more accurately, they’ve listed the costs, but not the pleasures that might balance them.)  What I’ve previously thought is naivety about policymaking or reality is, I think, arrogance.  A belief not that government making decisions about personal pleasures is wrong, but simply that they’re making the wrong decisions.

Back in the first few months I was writing this blog, I said that the most powerful and fundamental argument the alcohol industry could make in relation to alcohol policy would be based on liberalism, not on the technical details of research and modelling.  I understand why it might help to undermine or muddy the waters of ‘public health’ evidence, but that’s not really the fundamentals of this debate.

The same applies to drug policy reformers.  The debate is fundamentally about freedom: why should one person’s preferred drug (alcohol) be legal, while another’s (cannabis, or MDMA) is illegal?  Harm helps frame this debate, but it can’t drive it.  That’s not a question of naivety or pragmatism, but ethics.  Drug policy really can’t just be about science.

*Hence the Delphi model of research so favoured in these approaches.

Thinking beyond a spectrum of alcohol use

It’s January, so I shouldn’t really be surprised there seem to be a lot of stories about alcohol in the press and online.  The particular one that’s caught my eye is this academic response to the ‘new sobriety’ movement, and an exchange on Twitter.

Alcohol Change UK could claim all this as a success, given that much of this is due to the prominence of ‘Dry January’.  (For those who aren’t aware, this is a voluntary commitment to give up alcohol for the month of January.)

Last year (as in most years) I wrote about some of my misgivings about the campaign - or rather, about how it’s interpreted.

Perhaps most obviously, we know that the people most in need of ‘behaviour change’ (and therefore support) tend not to undertake Dry January, and if they do then they’re less likely to complete it successfully.

One interpretation would be that this isn’t necessarily a bad thing: stopping completely in the way Dry January implies isn’t appropriate for some of the people most in need of support, if they’re physically dependent on alcohol.  And we shouldn’t be surprised that the people who have the most entrenched issues find it hardest to give up – that’s the definition of having a more serious problem.

What’s been on my mind this year is a slightly broader interpretation of this issue.  It’s not entirely new, but I think it’s worth highlighting. And as I do, I think it’s also worth mentioning that, unlike last year, I’m actually doing Dry January this year.*  This is absolutely not a post attacking the campaign.  The point is that I think anyone in the field should feel obliged to use this moment of media interest to raise wider questions around alcohol, rather than simply trumpeting the merits of ‘choosing’ to stop drinking for a month.

If you look at the evaluation of Dry January, it tells us what we’d expect for any similar behaviour-change programme: successful participants (defined as completing the month without consuming any alcohol) are most likely to be women, to have a university degree, and to be on a higher-than-average income.  They’re also more likely to report good physical health at the start of the month.

As I say, this isn’t really a surprise.  We know from other areas of public health that these characteristics make people more likely to find success in these kind of campaigns based around individual choice.  And that’s fine; it’s horses for courses – some approaches will work for some people and not others.

The danger is that those factors that make people more likely to find behaviour change approaches helpful are exactly those that mean they’re less at risk of harm in the first place.  Because harm from alcohol isn’t simply correlated with consumption.  (The ‘alcohol harm paradox’ shows that although it’s the richest in society who tend to drink the most, it’s the poorest who suffer the most health harm related to alcohol.)

This is where it gets interesting.  At the same time as there have been various pieces written about Dry January, I’ve seen a few things about ‘alcoholism’ and the idea of a spectrum.  In fact, they’re kind of prompted by each other.

Amy Dresner has expressed some frustration with the ‘new sobriety’ movement (which some would see Dry January as being linked with), because it underplays how difficult just ‘choosing’ not to drink can be for those with a more serious issue – which she labels as ‘alcoholism’.  I’ve written about this idea of alcoholism before,

James Morris has suggested that this perpetuates an unhelpful alcoholic/not alcoholic binary, when the reality is that people will be facing a range of issues across a whole spectrum.  Just because you don’t fit the classic definition of ‘alcoholic’, doesn’t mean you don’t have an issue with alcohol.

I guess inevitable to some degree Dry Jan etc will be contrasted with abstinence based recovery etc.

Again though this is a false binary - the 'alcoholic or not' qu. may be a default reference point but for most alternative framings need wider promotion

— James Morris (@jamesmorris24) 2 January 2020

What I want to suggest here is that we need to see this spectrum as something more than a one-dimensional discussion of the severity of alcohol issues.  This has been proposed before, with people like David Nutt saying the best way to understand problematic substance use would be to abandon terms like ‘addiction’ or ‘alcoholism’ and simply look at ‘heavy use over time’.

Currently, though, when people think about problems with alcohol, these aren’t just about alcohol.  In diagnosing a ‘substance use disorder’ you might well look at consequences to someone’s home, relationship, work and so on.  In very few cases are these issues likely to be solely the result of substance use.  Things can enter a vicious circle, of course (substance use might intensify as other problems mount, as a form of escapism that only serves to make things worse).  But I mean something more than that: other issues may mean that the consequences of a particular level of alcohol use are worse for one person compared to another.

In a strange way, the reason there’s potentially tension between people who subscribe to a narrow definition of ‘alcoholism’ and those who advocate ‘new sobriety’ is that they share a lot of the same ground.  Alcohol is seen as absolutely crucial to both.

According to AA, the ‘alcoholic’ is a specific category of person who effectively has an ‘allergy’ to alcohol, and is best living without it entirely.  According to some of ‘new sobriety’ narratives, all the person had to do was remove alcohol from their life and they were suddenly able to wake up early with enthusiasm for their job (or with the passion and clarity of vision to start something completely new), and able to buy a house, and build better relationships with friends, family and lovers.

First, I should point out that both of these are caricatures.  In AA it’s widely accepted that the hard work starts once you’ve stopped drinking, and there are plenty of ‘new sobriety’ style advocates who would say the same.  And the reason the narratives are similar is because often we’re talking about people who have faced the same, serious issues.  As Amy Dresner points out, ‘If you CANNOT do a full month without drinking or if your life gets exponentially better when you stop drinking you might actually be an alcoholic’.  Chelsey Flood and Lucy Rocca are particularly good examples of people who could be seen to bridge the gap between these two camps.

But the point remains: in both narratives, alcohol is central and fundamental.  For ‘alcoholics’ there’s no life without removing alcohol, and for ‘new sobriety’ advocates’, just removing alcohol improves life immeasurably.

And this helps explain why Dry January works for some people.  Let’s go back to those successful Dry January participants.  They didn’t just tend to be healthy, highly educated, female and well-off.  They tended to believe they had a problem with alcohol, and this was confirmed through their AUDIT questionnaire (though of course this is dependent on self-reporting – we may each define problems and issues in different ways).

This makes sense psychologically and sociologically: we’re more likely to address a problem and persevere with solutions if (a) we genuinely believe it’s serious; and (b) we have some key resources behind us (‘recovery capital’ as they’re sometimes called) to support us.

In reality, for most of us who have issues in our lives and who drink what some people would see as ‘too much’, the precise role of alcohol is less clear.  Perhaps I’ll be proved wrong by the end of the month, but my previous experience suggests that I do not some hidden passion or clarity of vision that is simply waiting to be unleashed once alcohol is removed from my life.  And I can’t see that the things that make me angry or upset, for example, are going to be resolved by drinking less.

But it’s about more than that: it’s that for plenty of people you could remove the alcohol from their lives and things wouldn’t get demonstrably better.  Or it’s not just about removing alcohol to reduce their risk of health damage.  (Think of that alcohol harm paradox work.)

Therefore, if there’s an axis of ‘severity of alcohol use disorder’ that’s relevant to problems, there could also be another axis representing how much this is really about alcohol.

What does this mean for policy and advocacy though?

It means that anyone who’s serious about reducing ‘alcohol-related harm’ needs to think about more than just how many units people consume.  This is partly about patterns of consumption, but it’s also about wider social factors – exactly those things that make some Dry January participants more likely to succeed than others: wider health, employment, education, income, and so on.

This has clear implications for how we support people who do have issues with alcohol.  These can’t simply be addressed by appealing to individual choice, or by focusing on a person’s drinking.  There’s a need for services arranged around people’s actual lives as they live them.  (I’ve written about this before – for example here and here.)

There’s also a need for policies that address the wider structures that shape people’s choices and their lives – something that I’ve suggested in the past the sector has neglected, in its tendency to focus on a single initiative, whether that’s minimum unit pricing, alcohol labelling or Dry January.

So what does this mean for the value of Dry January?  It’s potentially helpful for a lot of people at an individual level, but for me its key contribution is about culture change, which then provides a space for policy change.

First, it prompts everyone to think about their alcohol consumption, and that fits perfectly with Alcohol Change UK’s admirable goal of getting everyone to make well-informed decisions.

Second, it provides an opportunity for commentators and policymakers to note that alcohol isn’t just any other commodity, and for all its strengths the individual-focused approach of Dry January doesn’t work for everyone, so we need more.

Anyone not making this case when talking about Dry January is, in my view, missing an opportunity, and even perpetuating health inequalities.

*Disclaimer: I did drink on 1^st January, so I’ve started late.  Someone who had come to our New Year’s Eve party had brought a ‘polypin’ of about 9 pints of locally-brewed beer, and not all of it got drunk.  My Presbyterian heritage of ‘waste-not-want-not’ in this instance overrode the Presbyterian tradition of temperance, and I drank the remainder on New Year’s Day in front of the football on the TV.