What do we mean by 'drugs'?

Last week I was at a really interesting conference on psychoactivity and drug policy at Warwick University, and was surprised and honoured to be speaking on the same programme as the likes of Stuart Walton and Toby Seddon.

(Unusually, I was also genuinely impressed by the publicity they included in the conference pack – there’s some great work in the humanities going on there.)

The theme of the conference was prohibition, particularly in response to the Psychoactive Substances Act, which may or may not be implemented in the next month or two.  Given the media coverage of the Act this week, I think it's timely to comment on some of the discussions we had.

(Personally, I can’t see the government not implementing this.  Just because a ‘go live’ date hasn’t been set yet doesn’t mean the policy has been abandoned.)

The position of most people at the conference was opposition to ideas of prohibition, whether from a libertarian or harm reduction perspective.  For me, this debate centred on the concept of ‘drugs’.

Fundamentally, many people’s opposition to current drug policy is rooted in a feeling that it is unjust to have some substances legal and others illegal, when there isn’t a great deal to choose between them in terms of their inherent chemical or pharmacological properties.  Why is alcohol legal and MDMA not?  Chocolate and tobacco, but not cocaine and cannabis?  Julian Buchanan is a particularly vocal exponent of this position, using the phrase ‘drug apartheid’ to describe how some substances are considered consumer products (tobacco, alcohol, etc), others medicines (methadone, morphine, sativa), and others ‘drugs’ (heroin, cocaine, LSD).

At the conference, Toby Seddon suggested that, if we try to understand what that last category of ‘drugs’ means, the only thing these substances have in common is the way they are regulated.  They don’t have similar origins, histories or effects (in terms of either mind-alteration or health harm).  He suggested that any attempt to prompt a rethink of drug policy would need to question that concept of ‘drugs’, which currently simply reinforces the ‘apartheid’, as Julian Buchanan would put it.  If people keep referring to ‘drugs’, then they’re using a category that only functions as a tool to maintain regulatory distinctions between substances – precisely the distinctions they want to question.

An interesting presentation came from Kojo Koram, who offered a reminder of how these distinctions can be entrenched.  The 1961 UN Single Convention on Narcotic Drugs uses the word ‘evil’ multiple times in its preamble (p.23 in the pdf here) – a word that doesn’t appear in the comparable sections of conventions on slavery, or even genocide.  It is this moral framework around ‘drug’ use that helps maintain the status of certain forms of use (whether classified as pleasure-seeking, self-medication, addiction or anything else) as problematic.

Stuart Walton argued that what is required is a public challenge to these assumptions and this framework.  Those in positions of influence should speak and act in accordance with their beliefs while they are in a position to change things; not simply afterwards, once they have safely retired or changed jobs.  And people regardless of their power or influence should be open about their use of substances past and present – as also encouraged by Carl Hart – to help break that association between ‘drug’ use and ‘evil’.

My presentation was somewhat different, but focused on the same ideas: that the concepts we use to understand policy are hugely influential.  Given the tone of the event the night before and the conference itself was strongly against what was defined as ‘prohibition’, and highly critical of the Psychoactive Substances Act, I wanted to present some thinking that might be not simply critical, but constructively critical (thinking of the ever expanding list of rules of drug policy and Robert Maccoun’s suggestion that “Experts like to have it both ways; we hold the government to higher standards of proof than we apply to our own policy opinions”).  I wanted to ask whether there could be a sympathetic interpretation of the Act.

I’m not sure I entirely believe my own case, but I wanted to offer a bit of nuance to the claims being made.  My point was relatively simple: ‘psychoactivity’ has replaced ‘harm’ as the concept by which drug policy in the UK is justified.  ‘Psychoactivity’ might not be easily definable, but it is potentially more transparent and realistic than ‘harm’.

Before the Act, UK drug policy was structured around the concept of ‘harm’, and this is still the organising principle for much reform activity – the claim that we should legalise and regulate, or at least decriminalise, ‘drugs’ in order to reduce the harm to users.  The Advisory Council for the Misuse of Drugs (ACMD) was there to offer the government expert opinion about the relative harms of different substances, which would consequently be controlled to varying degrees using the classification system (Class A, Class B, Class C).

The Act replaces ‘harm’ as a way of regulating substances with ‘psychoactivity’.  Substances would no longer be assessed based on their likely harm to users; they would be banned regardless of harm if they were being bought or sold as having a psychoactive effect.  Of course this would in principle ban alcohol, nicotine and caffeine (not to mention several other substances) so explicit exceptions have to be made.  Originally, I thought this might open out discussion to consider why those substances are allowed and others aren’t – and this has happened in public debate, but the government’s position hasn’t changed.

But my argument in the conference paper was that this position might actually be justifiable based on research from history and the social sciences.  First off, the idea of ‘harm’ from substance use is hugely complex.

It could be harm to others, through use of the substance itself, as in passive smoking, or more indirectly through what Liam Donaldson called ‘passive drinking’.  It could be harm to the user directly – but this could take a variety of forms.  It could be that there’s a risk of death, or perhaps a risk of disability or sickness.  And these risks could be from chronic exposure to the substance, or from particularly severe or problematic acute exposure, or particular patterns of use, or through combination with other risky substances or behaviours.  (Here I'm mostly paraphrasing the discussions about alcohol harm at the recent Alcohol Research UK conference.)  Interestingly, when we think about drug deaths we tend to think about overdoses, while alcohol deaths tend to be seen as due to chronic diseases, the result of heavy use sustained over several years.

So you can see that any attempt to compare the potential harm of different substances is fraught with difficulty.  It will inevitably mean looking at a whole range of factors, and weighting them against each other – as you can see from this attempt by David Nutt and colleagues.  Just look at the sheer number of colours there have to be to identify all those potential harms.

A further complication is that these harms aren’t guaranteed.  As the Police are fond of pointing out in relation to new psychoactive substances, using certain substances might be described (if you’re prone to more than a little exaggeration) as ‘Russian Roulette’.  The key to this is the idea of ‘risk’, the problem being that we humans aren’t terribly good at understanding risk – as shown by the confused debate around the recent new alcohol consumption guidelines.  All this means that it’s difficult to put a single number on the harmfulness of a substance.  And that shouldn’t be a surprise to any historian or sociologist of drugs - though for a slightly different reason.

Think of Howard Becker writing about learning to get high from marijuana; Mary Douglas talking about ‘constructive drinking’; Norman Zinberg talking about drug, set and setting; MacAndrew and Edgerton talking about ‘drunken comportment’; or Dwight Heath on the anthropology of alcohol use.  All these authors note the importance of patterns of consumption and the culture or learned behaviour around substance use in determining both practices and harms.  Of course this isn’t to deny what might be called ‘objective’ effects or harms of substances; the point is that how these translate into harms isn’t straightforward.  When considering the likely harm of a substance in a given society, we should be thinking about the norms around its consumption.

This isn’t an original or blinding insight, but it is worth remembering, as it means that policy can’t – or rather shouldn’t – really be made on the basis of a purely scientific assessment of a substance’s properties.  But what’s that got to do with psychoactivity?  Well, the way that concept is applied in the Act is precisely how Toby Seddon or Julian Buchanan would identify ‘drugs’ in policy discussions: it means all those things that are illegal (or we want to be), since it explicitly excludes alcohol, nicotine and caffeine from the category.

And maybe that’s justifiable, given the evidence around harm and social context.  There’s a legitimate argument that given a society’s history and present circumstances, different substances with ostensibly similar pharmacological properties shouldn’t necessarily be regulated in the same way.  This is the thinking behind dividing societies into ‘wet’ and ‘dry’ in relation to their attitudes to alcohol.  Some societies have developed stable ways of dealing with well-established substances, but might not be able to have the same social control over a new substance.  I think this is a simplification of the different ways in which we relate to alcohol, but it's a pervasive model, and there should certainly be some acknowledgement of the importance of social context to harm.  The point is, policy based on the sociological and historical research on intoxicants wouldn’t necessarily apply a single standard to all relevant substances.  And a scientifically determined concept of harm, based on the inherent properties of a substance, wouldn’t be able to make these distinctions.

If people have quite different understandings of two very similar substances, it’s reasonable to acknowledge those understandings as misguided or irrational – but it would also be rational to control the substances in different ways to take account of the different way people react to them.

In practice, this is how the Government is using the concept of psychoactivity: to designate substances the government thinks, rightly or wrongly, we're not in a position to safely legalise, due to the social context.  (Or perhaps I should say, they're not in a position to safely legalise, due to the political context.)  And based on the scientific, historical and sociological evidence, there is a sense that psychoactive substances have dangers (even alcohol is ‘no ordinary commodity’), and, because of cultural factors, we can’t treat all substances that have the same apparent level of psychoactivity or toxicity in the same way.

This doesn’t mean that the UK government is right to ban MDMA, LSD, nitrous oxide and a myriad of other substances.  But it does make the apparent inconsistency a coherent position.  It is partly historical accident (and as Virginia Berridge and others would point out, a relatively recent historical accident), but there’s no avoiding the fact that currently illegal substances occupy a distinctly different position in our society to those longstanding legal substances such as caffeine, alcohol and nicotine.  Of course the fact that other substances have been legal – or differently regulated – in the relatively recent past suggests that it’s not unrealistic to imagine such a situation could be instituted again.  And that might not be a bad thing.  I’d hoped that those ‘disruptive innovations’ of e-cigs and NPS might prompt a rethink of current drug policy, and to a certain extent it’s disappointing they haven’t.

But to rail against the Psychoactive Substances Act as being incoherent, inconsistent or hypocritical is not only to subscribe to a naively rationalist view of policy, but also to neglect the hugely valuable contribution of history and social science to the study of intoxicating substances.  We can't – and perhaps more importantly shouldn't – rank substances according to some apparently objective, unchanging, ahistorical notion of harm.

That's perhaps an oversimplification of what Nutt and colleagues, and various campaigners have been trying to do, but I'd still suggest that's the frame by which they justify their approach.  And it's not only unrealistic; I'd suggest it's actually undesirable as an ideal.  If alcohol isn't an ordinary commodity, new psychoactive substances are even less so.  So perhaps ‘psychoactivity’ in the new Act is simply a synonym for ‘drugs’ as colloquially understood, as reflects the continuing influence of ‘drug apartheid’ – but we should be careful of extolling the benefits of a pure, objective, rationalist drug policy: there’s plenty of social research that suggests this wouldn’t fit with how we actually understand and use different substances.

It may not be a perfect policy, but let’s not be too quick to dismiss the Act as unthinking or arbitrary.  Maybe the Act, for all the critique, actually presents a more coherent approach to drug policy than ‘harm’, which simply points to an apparent inconsistency between legal and illegal substances.

Update 06-04-16:
You can hear me discussing some of these issues with Steve Harris of BBC Radio Solent on their 'Breakfast in Dorset' programme on the day the Act was meant to be introduced - but wasn't - here.

Individuals, society and desirable drinking

I spent a great day on Wednesday at the annual Alcohol Research UK conference.  There was a huge amount of evidence on show, and discussion about the nature of evidence-based policy, how research can produce impact and shape policy.

The discussion really boiled down to whether there could be a common language, and genuine communication between researchers and policymakers.  There was consideration of all the usual themes of academics being cautious about their conclusions, and working over long timescales, where politicians want the 'killer' study that gives them a definitive answer to a policy problem.  In fact, there's a point to be made that researchers too are looking for that perfect answer.  We isolate factors, control for variables, and try to identify causes.

Tom Parkman got to the heart of things in the final session, raising the question of whether alcohol was the cause of various problems, or whether the drinking was the result of (for example) housing, employment or relationship difficulties.  He described this as the 'chicken or egg' conundrum, but that's really a shorthand for the fact that these issues are mutually reinforcing – as he suggested, once problems are established and chronic, is there any value in identifying which came first?  It might be more helpful just to get on with an intervention that addresses problems as they stand now.

And actually researchers aren't great at this.  We can trot out 'complexity', but still don't often manage to move constructively beyond that to conclusions or suggestions that are relevant to policymakers.  It's no good responding that things are more complicated than policymakers would like, unless we can offer an alternative interpretation or proposal.

How do we represent that complexity?  Often a quantitative study identifies the specific contribution of alcohol to a 'complex' problem, as if then a controlled intervention can singly address the alcohol issue, while some other intervention or organisation deals with the bit that relates to housing, or employment, or whatever else has been controlled for in a regression analysis.

Qualitative studies often conclude by metaphorically throwing hands in the air and suggesting (correctly, but not always helpfully) that 'it's a bit of everything'.  The problem is 'complex' or 'wicked'.  And we tend to invent our own terms to try to make sense of things.  There's any number of typologies of drinking patterns – but how have these been translated into interventions or policy?

Here's where the fresh eyes of a more quantitative team were helpful.  John Holmes described some new work from the famous Sheffield Alcohol Research Group analysing drinking diaries to identify particular forms of drinking occasion, offering much-needed contextual data (but in a systematic way) to the overall consumption data that tells us only amounts and frequency.  I can see their typology of drinking occasions being genuinely useful – taking the work of Mark Bellis' team to the next level.  It's an example of acknowledging the situation is complex, and can't be accurately addressed with a single 'killer' answer, but still providing something that you can imagine being communicated to a policymaker.

But John closed his presentation by raising another key issue.  We know that 'harm' isn't easily defined, and we know that even if we do define it very tightly, we can't make a totally straightforward link between consumption and that harm.  We need that contextual information, about quantity per occasion, and other factors such as whether food was present, family or friends, and so on.  That is, harm isn't simply dependent on consumption levels; it's affected by drinking cultures.

So if we're not going to simply aim for prohibition or zero consumption of alcohol – if we're prepared to accept, as most people in the room seemed to be – that there could be positive, or neutral alcohol consumption, we need to define what a 'desirable' drinking culture might be.  What 'should' policy be aiming for?

And in the context of references to sociology and social anthropology, that makes complete sense.  There is no doubt that drinking 'cultures' affect harm, as well as simply consumption levels.  Sociologists by definition are interested in studying society, as much as individuals.

But policymakers aren't all sociologists.  The analysis doesn't simply translate into policy, as we heard so often during the day.  In this instance, it's because of a frame that defines what is appropriate for government to do.  We could argue over what a desirable drinking culture might look like, but that's a second order question.  First we'd need to have agreement that government be in the business of fostering 'culture'.  This would sit at odds with Margaret Thatcher's reasonable (and selectively quoted) statement that 'there is no such thing as society'.  This plain statement was actually very sensibly qualified by the observation that there are individuals and families.  This is really a claim about the appropriate unit of sociological and policy analysis: should we look at groups of people (who are only 'latent' classes, to use the terminology of John's paper) or should we look at the individuals themselves.  (I'd quibble with Thatcher's assumption that families are not a concept that needs unpacking, but that doesn't challenge the overall approach.)

It is an unavoidably political discussion not just to define what an acceptable drinking 'culture' is, but to even suggest that government should be thinking at the level of 'cultures'.  Much as I'm sceptical of the utility of the term (although it's been very useful in getting me publications in academic journals), this is a questionable claim while (if?) we live in a neoliberal political environment.  According to that orthodoxy, the unit of analysis is the individual.

And in fact, that's an appropriate place to end and bring this post full circle.  An individual, as Bauman pointed out, originally means something that is indivisible.  And that individual, as Tom Parkman's research suggests, can contain plenty of interacting factors (housing, employment, physical health, personal relationships, mental health, drinking practices etc etc).  But they are indivisible.

And, echoing Wulf Livingston from Tuesday's symposium, perhaps that's where we should start and finish: what does desirable drinking look like, not to policymakers, or public health professionals, or academic researchers, but to drinkersand the wider public themselves.

Michael Gove, Power, and the EU

I don’t often blog on general themes of politics here.  Mostly, I stick to issues relating to alcohol and other drugs.  That’s simply because that’s the area I know best, on which I spend the most time.  But the original purpose of the blog was to discuss public policy issues where I felt there wasn’t clear debate.

I’ve talked about university admissions before, but this time I’m going to touch on the EU referendum.  Not to get into the substance; I simply don’t know enough about that.  But to apply some relevant understanding I do have (of political and sociological theory), to suggest that the debate risks missing the point.  I’m specifically going to discuss Michael Gove’s statement on why he will be campaigning for withdrawal from the EU.

The whole argument, it seems, comes down to his worry about his own personal power.  ‘It is hard to overstate the degree to which the EU is a constraint on ministers’ ability to do the things they were elected to do, or to use their judgment about the right course of action for the people of this country.’

This might be a fair enough point, if it was making the case that decisions should be devolved closer to the people they affect, and that a UK minister is another step closer to the people of their country than an EU politician.  Certainly there’s a sense in which the UK government has more control over UK policy than EU-wide policy.

And this is to some extent the fundamental issue: how small should units of government be?

(On this point, Gove makes a disingenuous comparison with the United States, suggesting that just as they fought for their freedom through the War of Independence, we should take our freedom from the EU.  Given the role and autonomy of states within the union, a case could be made that in terms of distance from voters’ lives, the federal government has in much in common with the EU as it does with the UK government within that EU.  To take slightly flippant examples from my field, the legal status of different substances, like cannabis, and the age at which you’re allowed to buy alcohol vary by state in the US, and nation in the EU.)

But this question of how close power should be to citizens betrays Gove’s simplistic approach to power.  This might well be a trick to make his argument more persuasive, but as I write so often on this blog, that might be even worse than if he genuinely believes what he is saying.

There is not, cannot be, and never has been a situation where a minister in Whitehall – or any other person ‘in power’ – can issue commands that are simply enacted.  This is partly because of ‘street level bureaucrats’, who will actually be implementing any policy or diktat, but it’s also because the idea of ‘control’ that Gove seems to envisage is impossible.

He states that ‘government is not, ultimately, in control in hundreds of areas that matter’ – but this is not the result of the EU; it’s the inherent nature of power.  The EU is a useful scapegoat, but no government has ever had ‘control’ of the economy, for example.  Even if it left the EU and took back direct responsibility for setting interest rates, the UK government would not be able to magically command employment, wages and growth rates.

But perhaps if Gove doesn’t mean controlling the outcomes of policies, or even their implementation, he simply means ministers should have autonomy in setting policies.  In reality, though, this too is a charade.  The world in which ministers could say ‘this is what our policy should be’, and it could be implemented, is impossible.  Their choices are constrained by a myriad of factors, from international governments and corporations to sectional and electoral interests at home.

Of course, that’s the nature of politics: to look at a range of arguments and interests and come to a compromise.  And it could be that’s the vision of politics that Gove is aspiring to: his ministerial compromises will be better without the institutions of the EU involved.  His judgement will be improved by making a political calculation about the informal or putative constraints posed by the European context, rather than having formal constraints already written out.  (Of course he’ll still have to pay attention to the European Court of Human Rights, but that’s another story.)

In a sense, though, that’s less transparent for the voter.  If he can identify why he can’t enact a particular policy (it’s EU Directive X) that might be clearer than if he had to explain how that policy might spark a response from other countries, and he’s calculated it’s not a risk worth taking.

But all this is a sideshow.  For all that central government talks of a new approach to governing and commissioning that focuses on ‘outcomes’ and not processes, Gove’s thinking is all about process.  We should be having a grown-up debate in which the EU is understood to be just one (unusually clear-cut) constraint on ministerial decisions amongst plenty of others, and where there’s an acknowledgement that in any case ministerial decisions have a long way to go before they affect people’s actual lives.

Maybe then Brexit is the answer.  It would remove what is often a diversion from the real constraints and issues in politics, and might force politicians to admit that Gove’s statement is truer than he would admit: ‘your government is not, ultimately, in control in hundreds of areas that matter’.

That’s quite a price to pay for a ‘told you so’ feeling.  This vote isn’t about simply taking ‘control’.  It is at best opportunity to swap one set of constraints for another – and that makes it even more important we talk honestly and openly about what those constraints are and might be.

Thinking beyond population harm and addiction

I often mention on this blog the range of problems that are associated with alcohol, and how this can muddy the waters when we try to discuss alcohol policy: are we worried about violence and antisocial behaviour linked to ‘binge’ drinking; health and social problems resulting from addiction or dependency; or the risk of health harm due to long-term use?

I was reminded of this yesterday for two reasons: a neat diagram I saw on Twitter from James Nicholls; and a conference I attended discussing the links between intimate partner violence and substance use, and how to address this.

James’ diagram showed a summary of how alcohol problems have been understood and the dominant policy approach taken by campaigners – for example, a belief in the 18^th century that spirits produced a new and dangerous type of drunkenness, and therefore that they should be specifically controlled (and perhaps beer consumption encouraged instead).

The example given for policy today was that campaigners have moved away from focusing on addiction as a disease (and therefore targeted treatment as a solution), towards a preference for understanding alcohol problems as being on a continuum, and the appropriate solutions as being focused on the supply of alcohol (e.g. price and availability).

The only problem with this way of thinking (and I’m not criticising James, just the public debate he’s analysing) is that if there’s a whole continuum of alcohol-related problems, it seems odd to focus on availability as the solution.

There is a strong argument that reducing availability affects use and therefore to some extent the scale of social problems associated with substances.  A key reason (though not the only one) why there aren’t that many heroin users in Britain, and there are far fewer heroin-related deaths than alcohol-related deaths is that it’s not as easily available.

(Of course heroin us isn’t as socially acceptable as alcohol use, but again the two things (availability and a culture of consumption) are linked: alcohol is available all over the place – and supported by politicians as an industry – because it’s socially acceptable, but it’s acceptable (or normal) partly because it’s so visible and available.)

But all that doesn’t mean that availability is the only game in town; it’s certainly not what most drug campaigners focus on.  Whether you have a relatively free market in substances, one that’s reasonably well-regulated, or one based around prohibition, you’ll still have people using substances who need some form of help to reduce the health and social harm caused by their use.  Current treatment services in the UK have plenty of users of both alcohol and heroin.

You can call that level of use ‘addiction’, or ‘dependency’, or ‘heavy use sustained over time’, or you might be thinking of ‘risky single occasion drinking’ – and all those might describe genuinely different patterns of use that imply a need for different sorts of support.

And that’s where the debate in the UK has fallen down.  There’s a tendency to leap to see either the substance (alcohol) as the problem, or identify particular people (alcoholics, drunks, or whatever label is in fashion) as having weaknesses or vulnerabilities to it.  In the 20^th century stage of James’ model, although it isn’t seen as a person’s moral failing, particular people are picked out as having a ‘disease’.

There’s always an issue around stigma, though, when you focus on individuals.  Kettil Bruun argued that focusing on populations was a neat way to get around this – and you could still implement interventions on this basis that were effective for those most in need of help.

Some current commentators on substance use (notably Johann Hari) have tried to bypass this debate by plonking down (without admitting it) the old sociological concept of ‘structure’ to replace the ‘agency’ of the individual who might have a problem.  That is, it’s suggested that the problem doesn’t reside in particular substances (and people often replace an ‘addiction’ to one substance with some other form of addiction – to activities like shopping, sex or gambling as much as substances).  Instead, with frequent reference to ‘rat park’, the wider social environment is seen as the problem: people who have issues with substances variously need ‘jobs, friends, houses’ or social ‘connection’.

In reality, this doesn’t get us out of the debate on whose ‘fault’ addiction is, as any sociologist who’s tried to write about structure and agency would be able to tell you.  (Don’t get me started on Anthony Giddens and ‘structuration’.)  The reality is bound to be more complex, where some people’s issues will be primarily down to their social environment, others a genetic predisposition, others simply to the risks inherent in alcohol consumption, where they didn’t particularly have any other warning signs.  Most are a combination of a whole range of factors.

And this formulation still leaves us focusing on a particular cohort of people: those who are (whether we use the word or not) ‘addicted’.  And even if you’re not saying that individual has a moral or genetic ‘failing’, there’s still something stigmatising about pointing out which group in society is in greatest need of jobs, friends and houses, and social connection – and there’s a danger this plays into certain damaging narratives around ‘sink estates’.  When you hammer home the importance of wider social structure, there’s not much ‘agency’ left to that individual to find meaning and stop feeling powerless in their own life.

But what’s this got to do with intimate partner violence (IPV) and yesterday’s conference?

Well, you can see the ‘jobs, friends, houses’ narrative as having just the same aim as Kettil Bruun’s population-wide approach: make sure resources are there for those who need them most.  Only in this case, it’s a response to the fact that the population-level approach seems to be shifting attention from those with the least ‘recovery capital’ to those with the most: brief interventions and universal efforts to reduce everyone’s consumption just a little bit.  By reminding us of the need to focus interventions on those who actually need jobs, friends, houses, we can target scarce resources most effectively.

(I should point out that this is only my speculation on the motives of some who’ve made these claims; probably not Johann Hari, who’s more concerned about stigma and a more liberal drugs policy.)

But as we talk about jobs, friends, houses (I know it’s getting tedious repeating that phrase) we’re really just talking about ‘addiction’ or ‘alcoholics’ in a new language.  We’re still focusing on one particular segment of a broader spectrum of problems.  And that poses a big problem for some of the possible responses to IPV that were discussed yesterday.

It was pointed out that while programmes to treat perpetrators of domestic abuse mostly run through criminal justice services, only a small proportion of those who commit these acts come into contact with the criminal justice system, and still less for these specific crimes, which is how people come to be referred to these programmes.  By contrast, a high proportion of those in substance misuse treatment admit to having committed IPV (though they wouldn’t necessarily see this as a crime, particularly where it doesn’t involve physical abuse).

This is the logic for hosting such programmes within substance misuse treatment services, or at least referring people through them.

And research with the partners of perpetrators that was presented at the conference by Ingrid Wilson suggests that alcohol is indeed closely related to IPV.  (And I have to say I thought her model of the stages of drinking and IPV was one of the best results of a grounded theory type approach that I’ve seen.)  But I’d suggest that the drinkers described by their victims had more in common with ‘binge’ drinkers – or perhaps those who engage in “frequent occasions of heavy drinking that [also] result in heavy volume drinking”.

And those are the people who don’t fit into that binary debate of population-wide or targeted measures, as long as we see the ‘target’ of treatment so narrowly.

If we really think there is a continuum of harm in relation to substances (and alcohol in particular), then we need to think of a full continuum of interventions.  And that means having more nuanced discussions than we do now.  Binary thinking might help frame some discussions, and will win some arguments, but it can’t give the full picture, or provide a complete answer.

In defence of alcohol guidelines

The last week or so has seen some pretty strong debate around the proposed alcohol guidelines published by the Chief Medical Officer.  I’d sort of assumed that, like many news events, this debate would be replaced by another issue after a day or so, but in fact a letters debate was still being printed in The Guardian on Thursday 14^th January – almost a week after the guidelines came out.

This debate, as I predicted when the guidelines were released, seems to have involved people talking past each other, often from ill-informed or inconsistent positions.  The letters to The Guardian are a case in point, so I want to spend some time here talking their criticisms through.

I should start by acknowledging my personal position in this, as I think this is important in how we react to guidelines.  I drink between 20 and 30 units most weeks – about 3 pints on each of Friday, Saturday, Sunday and Monday.  (For those of you who are wine drinkers, this works out at more than 2 or 3 bottles a week.)  I drank more than the ‘old’ guidelines, and I certainly drink more than the ‘new’ guidelines, as the threshold for men has been lowered.

I often feel torn on alcohol issues.  Thinking of a similar discussion about older people’s drinking, you could say I took a different position, challenging Jackie Ballard on her assertion that older people’s health would inevitably be damaged by increased levels of alcohol consumption.  The evidence we’d just been presented with flatly contradicted this point (which is a complete misunderstanding of the nature of risk and uncertainty).  There’s also a danger that if you tell people a certain level of consumption will definitely cause health damage they’ll switch as off, because they’ll probably know someone who drinks at that level and hasn’t suffered any harm.  That’s the nature of risk.

Equally, though, I’ve been quite supportive of the guidelines released this week, which have had exactly the same objections thrown at them.  I value having them even while I’m not exactly in step with their model of low-risk behaviour.

But I think this feeling of being unsure is appropriate – alcohol can be both pleasure and poison, even at the same time.  If we’re comfortable with a simple, coherent position, we’re probably missing something.

More than this, though, there is a difference between telling people what to do and giving them information.  It’s exactly why I welcome the advice, but don’t stick to the low-risk limits.

Jackie Ballard was wanting older people to drink less, and wanting to tell them so, based on what I saw as a misreading of the evidence.  This is exactly what the Chief Medical Officer and related researchers have been accused of in the past week or so, but in fact I’d suggest they’re doing something quite different.  They’re trying to offer information about risk to guide individual decisions.  (And this information only related to medical risk – so you may wish to balance it against the physical or social pleasures of drinking.)

14 units a week or less would be a good level for everyone to drink at from a public health perspective, considering overall population health outcomes like hospital admission rates, but it’s up to each individual to judge whether that sort of health improvement is of any interest to them.

There seems to be a school of thought that thinks because giving advice is difficult, we shouldn’t do it at all.  That is, each person has different genetic and environmental factors that will influence their level of risk, and so it’s impossible to give a single risk figure for all people in the population, making any single figure misleading.

But my response to this is that we use these single approaches in all sorts of elements of life.  We set a single age of criminal responsibility (apart from in exceptional cases), even though we know people’s maturity and powers of reasoning vary considerably.  We set a single speed limit even though different cars and drivers have different stopping distances.  In terms of health and lifestyles, we give single figures for recommended exercise or fruit and veg consumption.  I’m not saying these are all the right way to approach these issues, but the idea of a single target or recommendation is not unique to alcohol guidelines, or even unusual.  It’s a standard approach to advising and governing behaviour.

I would argue that if we’re making decisions that affect our health, it’s helpful to know the best information possible about how that might happen. 

This is why I think the letter written by Jack Winkler, Emeritus professor of nutrition policy, London Metropolitan University, is wrong when it complains that we need a more complex response, ‘not just admonitions’.

In fact, it could be seen as dishonest to provide medical professionals with tools by which to screen people for problematic alcohol consumption, and then not give drinkers themselves access to the same information.

One main argument – put forward by Sally Caswell previously and Chris Hackley more recently – seems to be that giving out limits puts the onus on the individual to manage their own risk, and distracts from lobbying from more effective controls on price, availability and so on.

As I’ve noted before – and did when these guidelines came out – there is a genuine concern that recent trends in government policy focus too much on individual decision-making, neglecting the wider context that shapes these decisions.  (This is what is generally meant by neo-liberalism in a social policy context.)  So I’m sympathetic to the idea that guidelines could distract from other elements of the alcohol policy picture.

However, I’d draw attention to Nick Heather’s response to this.  The simple answer is that if alcohol is legal and available in any form, individuals will be making decisions about how much to consume and in what format, pattern and setting.  These decisions unquestionably affect a person’s risk of health harm.  And there is, unavoidably, a certain sense of responsibility.  This is not simply ‘victim blaming’, but an awareness that we make our own decisions, though not always in circumstances of our own choosing (to badly paraphrase Marx).

Chris Hackley has responded by pointing out that the research is already out there, so why have (simplifying and misleading) guidelines?

But these letters to The Guardian show that even making the research available alongside the guidelines doesn’t mean it will be read and understood.

David Lewis from York writes that “The guidelines conveniently ignore the evidence around the cardioprotective and neuroprotective effects of moderate alcohol consumption.”  They absolutely don’t.  There’s careful discussion of this in the Sheffield model, and that’s part of why the guideline isn’t set at zero despite the fact that for many conditions there is no ‘safe’ level of consumption.

Dr John J Birtill from Guisborough in North Yorkshire states that the guidelines “tell us nothing about how much longer the non-drinkers will live on average, the range of this extra life expectancy, the quality of life during the extra years, or the likely alternative causes of death. The lifetime benefit of abstention might be rather small compared to the lifetime pleasure of moderate alcohol consumption.”

In themselves, perhaps they don’t; they’re just low-risk guidelines.  And any condensing leads to interpretation.  But the report they’re written into does talk about precisely these issues, and the Sheffield report gives even more detail.  These things aren’t being hidden; they’re part of the discussion.

And the whole point of Millian liberalism is that the individual is best placed to decide about their own ‘pleasure’ in various activities, so it would be odd if the state stepped in and said this is where the perfect equilibrium lies.  This correspondent seems to be objecting the fact that the state hasn’t done this, at the same time as complaining that effectively it has.  I’m confused.

Some of those writing in are clearly highly motivated to find out about this issue, and highly qualified, seeing as they’re listed as doctors and professors.  And yet they’ve failed to read (let alone understand) what’s already available and clearly signposted.  So what hope would the rest of us (most of whom aren’t actually that interested in the detail) have of finding out and understanding without providing these simple guidelines?

So I still can’t see what harm having guidelines does.  And if we’re having them, what’s so wrong about something that gives the level at which you’re taking the same risk as the average car driver?

Sure, they don’t deal with all the myriad problems alcohol can cause.  And they won’t be effective for everyone.  And they aren’t the only policy tool available.

But while alcohol is legal, isn’t guidance on risk something a consumer should reasonably expect to be given?  In fact, we even give this kind of guidance about ‘safer’ consumption levels/patterns/settings with illegal drugs: always use with other people; never share or re-use injecting equipment; smoke rather than injecting; reduce your dosage after a period of abstinence; and so on.  Maybe alcohol users deserve the same courtesy we grant users of other substances?

Still hoping for a balanced debate

As I never seem to tire of pointing out, there are a myriad of perceived problems related to alcohol, affecting different people, and caused by different combinations of a range of factors.

It shouldn’t be surprising, then, that whenever a policy or evidence discussion occurs – like today’s debate about guidelines for low-risk drinking – it’s almost inevitable a lot of people talk past each other.

(I, of course, would never do that, and if you want to hear me talking to, or with, or at [certainly not past] a BBC interviewer, you can listen here.)

I’ve written before about how the word ‘addiction’ can sometimes confuse as much as it explains, and yesterday dragged some very reasonable and knowledgeable people into an argument about whether there are the same problems with the idea of ‘dependent’ drinking.

So what are these guidelines trying to achieve – because that will help us have a sensible conversation.

I think they do two really positive things.  First, they treat people like adults, giving them some information about risk.  Second, by making the statement that there is no safe level of consumption they help to stop people thinking of alcohol-related problems in terms of ‘alcoholism’, ‘binge’ drinking and liver cirrhosis.  In fact, alcohol consumption at a many levels, although it might not lead to any immediate damage or produce dependence, carries a range of risks in relation to cancer and other illnesses.

That this point isn’t readily accepted is illustrated by today’s Telegraph viewpoint, which suggested government focus on ‘a hard core of [people with] health and social problems’.  We’re very quick to pin problems on other people, namely those at the visible extremes of consumption.

These guidelines are not really for those who have serious dependency or addiction issues – and to say that government should only focus on these groups to miss a large element of the harm related to alcohol in our society.

(I could discuss that Telegraph article at length, but I hope I cover most of my objections through this blog post, so I will limit myself to saying it’s hard for people to gain the sort of experience through drinking that means we “know when they have had ‘one too many’” in relation to cancer risk.)

But even if we can see these guidelines as simply helping people make informed decisions, setting them isn’t simply about science and letting the facts of risk speak for themselves.  They need to be set at a level and explained in way that makes sense to people who are actually doing the drinking.  As Alcohol Research UK point out, there’s a danger that if you set the guideline too low then people just switch off and see it as unrealistic.

But then the ‘realism’ of the guidelines depends on who you’re trying to target.  We should remember that most people drink less than even the revised guidelines (85% of women and 68% of men), so by definition they are a perfectly ‘normal’ recommendation. 

And then there’s evidence that some people change their alcohol consumption if the issue is simply raised as a discussion, without much of a push from a clinician – and the discussion of these guidelines might help with that, particularly as they plant the seed of the idea that alcohol is an inherently risky product.

So we shouldn’t assume they will be ‘ignored’ – and to some extent saying can make it so, as the guidelines depend on their public reputation for their effectiveness.

Also, although I wouldn’t use the word ‘ignored’, it wouldn’t be a failure of the guidelines if lots of people looked at them and continued to drink above those limits.  The guidelines offer information about one element of life: long-term health.  They don’t tell you how to balance up those health risks against the various pleasures you might get from the social elements of drinking, the taste of your favourite drink, or the feeling of being intoxicated.  It’s perfectly reasonable to look at the guidelines and decide to drink above them on the basis that you’re prepared to accept that risk.

But if all that sounds very positive about the guidelines, despite my genuine concern about whether they’ll be ignored, I’ll end with a couple of notes of caution.

First, there is a danger that the guidelines reinforce a policymaking model where managing risk becomes solely the responsibility of the individual, when I would argue government can reasonably play a role in reducing some of the structures that expose people to those risks.

Guidelines shouldn’t be seen as the government’s key policy contribution to reduce alcohol-related harm.  They aren’t aimed at those with the greatest level of problem, and they won’t work as an intervention for everyone.

In that way, they can be attached from both ‘sides’ of the debate.  Just as the Telegraph complains that government should instead be focusing on ‘a hard core of [people with] health and social problems’, so some public health professionals would take the opposite view and suggest that this distracts from more effective population-wide regulation measures to affect price and availability.

From the latter viewpoint, guidelines can be seen as a classic neoliberal response to the issue from government: yes, we admit there’s a problem, but it’s up to you citizens to behave as responsible individuals to sort it out; there’s no need for collective action, just information and autonomy.  The observation can certainly be made that the government benefits financially from alcohol taxes, so why would it seriously look to reduce consumption?

(Thinking of a previous job I had, I can’t help but wonder whether some of those justifying these guidelines as only information to help people make ‘informed choices’ would condemn the document of the same name produced by the Russell Group to improve access to their universities.)

But I’d suggest that although it’s worth keeping an eye on this tendency to ‘responsibilise’ individuals, it’s not an argument against either guidelines in general or these new ones in particular.

I would worry about the guidelines if I felt they let the government off the hook in relation to other elements of alcohol policy, but I’m not sure this is the case.  If we didn’t have these new guidelines, would we have minimum unit pricing?  I very much doubt it.  I can’t believe this is a zero-sum game where MUP has been traded for new guidelines.

My second note of caution is that for many involved in this issue, alcohol consumption means nothing less than a campaign.  This could be said of Gerard Hastings and Ian Gilmore, who sat on the advisory group.  This isn’t to condemn them; we need campaigners, and there’s nothing wrong with having a position, particularly when they’re so open and honest about it.  However, there’s no doubt that if they felt attention was moving away from alcohol consumption and government was becoming complacent, they would be keen to draw attention to the scale of drinking and harm in the UK, and lower limits can help to play a role in that.

But these notes of caution are really, as ever, about how healthy this debate will be in the future, not about the detail of the guidance.

When we consider what happens next, let’s maintain some balance and realism.  The best starting point might be for all those involved in the debate to remember that most people drink within these guidelines, so while there isn’t necessarily a ‘crisis’ they’re not an unrealistic idea either.

The pleasures of intoxication

My thinking on drugs and alcohol is often structured around the idea of pleasure.  I’ve written in the past about how this isn’t a terribly useful way to make sense of what we do around drugs and alcohol, as no behaviour – least of all drinking in the night-time economy – can be made sense of using such a black-and-white term.  But there is occasionally a use in having this kind of concept in the back of your mind.

As regular readers of this blog and/or my academic work probably know, I’m quite a fan of Pierre Bourdieu.  He basically argues that class is about something more than occupation, income or market position – it’s about how these attributes fit into society’s wider ‘symbolic economy’.  For the concept of class to be at all useful, it has to mean something more than any of these individually – it’s the thing that links all these and the other correlated attributes that mean we can identify someone’s ‘class’ by the clothes they wear, where they live, what car they drive and what they do for pleasure.

His work was concerned with how these different perceived groups are made, and what effect that has on our lives in terms of personal and political possibilities.  The groups are made by ‘distinction’ – features of taste that distinguish one person (and hence one group of people) from another.

Central to this mechanism of distinction is the idea that, for the bourgeoisie, form is separated from function.  For example, in relation to food Bourdieu suggests that while the working class eat food that is simple and high in calories – and eat it in a functional, unpretentious way – the bourgeoisie eats daintier food designed almost to hide the fact that the food is about taking on energy.

He builds his whole position as a ‘critique of the judgement of taste’, to suggest that the rules of ‘good taste’ always serve a social function of distinguishing people from one another, through hierarchies according to broader systems of value.

The relevance for alcohol studies is the stories people tell around their drinking – why their practices are pleasurable (and therefore valuable).  As James Nicholls notes, the pleasures of wine drinking are often quite divorced from one of the key defining features of wine: its alcohol content.  This can easily be analogous to Bourdieu’s discussion of food: some value drinks that get them drunk; others emphasise other, seemingly peripheral, features – that wouldn’t be obvious to those not in the know.

In a sense, this comes back to JS Mill’s ideas about happy pigs (or, actually, satisfied pigs).

“It is better to be a human being dissatisfied than a pig satisfied; better to be Socrates dissatisfied than a fool satisfied. And if the fool, or the pig, are a different opinion, it is because they only know their own side of the question.”  John Stuart Mill, Utilitarianism (1863)

By positing something greater than intoxication (or immediate sensory pleasure), the thinking wine drinkers place themselves on the side of Socrates in this statement.

But having read Bourdieu on the subject, how can a thinking drinker stand by this claim?  Any statement of ‘I like this drink’ to mean something more than ‘I like the taste’ can immediately be analysed to show that there is nothing fundamentally valuable in this practice other than the meanings we create for it.

(I don’t mean to advocate complete moral relativism – I am assuming that the happy pig isn’t hurting other people.  And I’m exaggerating when I write that there’s ‘nothing’ valuable in the practice.  Watching football, for example, might be said to have benefits in terms of social solidarity, getting people out of the house and so forth.  But that’s not why people experience pleasure in the practice – these positive knock-on effects aren’t what get people down to the County Ground on a cold, wet Saturday in November.)

In the face of such criticism, how can we continue to find pleasure?  As soon as we’ve thought through that our liking for ‘real ale’ is partly down to the perceived resonances with some fictionalised version of the past, surely that pint suddenly doesn’t taste so sweet (or rather, bitter)?  Saying (or thinking) these things out loud makes them seem a bit ridiculous, doesn’t it?

And in any case, you only like the taste of that drink because of the way you were introduced to food and drink, which is simply chance.

One response, of course, is to say ‘so what’?  Of course we’re products of our environment and like things that resonate with particular tastes, experiences and principles we’re familiar and comfortable with.

But that would reduce the distinctiveness of the practice.  The whole point of distinction is that ‘good taste’ is pure in the Kantian sense – it’s unsullied by function, and it shouldn’t be simply a product of our environment; it’s genuinely ‘better’ than other tastes, otherwise it’s nothing: there would be no hierarchy.

Again, you might ask, ‘so what’?  But my query now is: if this critical sociological/psychological approach was more widespread and took root in how people think, wouldn’t the ‘purest’ form of taste be the most immediate?  That is, the most genuinely ‘disinterested’ taste, that which would demonstrate one’s intellectual superiority by being able to critically analyse one’s own pleasures and place oneself outside of one’s position in social space, would be sensory pleasures.  Socrates would come over to the side of the happy pig.

This wouldn’t be such a new idea, given the ‘libertines’ of the 17^th and 18^th centuries or the status of drugs for intellectuals in the 1960s, but it does offer a way to have pleasure (and status?) for the sociologist or cultural theorist inclined to overthinking, and I can drink to that.