Tuesday 27 August 2013

Addiction, medicine and local public health

The Chief Medical Officer, Sally Davies, caused a bit of a stir a week or two ago.  On BBC Radio 3’s “Private Passions”, she acknowledged that she had taken cannabis a few times, in cookies.  This excited the Daily Mail, mostly for the apparent scandal of a senior public (health) figure admitting to having taken illegal drugs.  Ears also pricked up in the world of drug and alcohol policy, though, as Davies stated that addiction was a ‘medical’ condition.

I’m not sure I agree.  The term addiction isn’t clear.  For a start, you can distinguish it from physiological dependency, which can wane relatively quickly, while addition persists – that is, if you follow the EMCDDA in defining addiction as the “repeated powerful motivation to engage in an activity with no survival value, acquired through experience with that activity, despite the harm or risk of harm it causes”.  (On addiction, it’s worth listening to the beginning of this Radio 4 programme on addition, or reading this book.)

To an extent this is simply to acknowledge the psychological element of addiction, and that doesn’t in itself mean the phenomenon isn’t medical.  However, I’d argue that this idea that addiction is – or should be treated as – specifically or primarily medical is unhelpful.

We know that people’s health is affected (even determined) by factors that might not be thought of as directly medical: inequality, housing, social networks, the built environment.  And someone’s ability to overcome an addiction is affected by their ‘recovery capital’ – pretty much those exact same factors.

To suggest addiction is purely medical runs the risk of implying that, as a physiological problem, detox or a methadone script should resolve it.  This could detract from the attention that should be paid to secure housing, employment, social networks and all those other factors that influence how likely someone is to recover.

This is one of the reasons to be cheerful about substance misuse treatment now being housed in local authorities as part of public health structures: in theory, this should make it more likely that public health interests will be taken into account across different areas of local policy, from schooling, through transport and planning, to licensing.

In fact, it’s one of the reasons to think that public health is the right place for substance misuse as an agenda generally: public health should be about all these wider factors.

However, as I’ve suggested before, given the way we understand and regulate intoxicants in the UK, health issues aren’t the only ones that relate to substance misuse.  For example, Paul Hayes, former chief exec of the NTA, has noted the importance of the crime agenda in garnering support for drug treatment within government.

As with the definition of ‘addiction’, it isn’t always clear what is meant when people talk about drug-related crime.  Peter Ferentzy is probably right when he asserts that much violence described as ‘drug-related’ would be better described as ‘prohibition-related’, in the same way as we talk about Al Capone’s exploits.  And the Guardian editorial that commented on Davies’ point made a similar claim, but to hint at the advantages in decriminalisation or legalisation.

This is of course one of the underlying aims when people talk about treating addiction as a medical problem: the ‘addict’ shouldn’t by definition be a criminal.  But that’s different to Ferentzy’s argument, where he’s talking about violence/crime relating to the trade in drugs, not the taking of the drugs.  And being addicted to something isn’t a crime in Britain.  What’s criminal is possession of illegal drugs.  In fact, you can access physiological and psychological treatment for addiction on the NHS.  (I should actually say: via your local authority through a range of local or national providers, public, private or charities, but free at the point of use).

When we think of addiction as causing crime, we’re mostly thinking about shoplifting and so forth to fund a habit.  And that is drug-related.  It might be that legalisation could reduce crime – but only if people funded their use without committing crime.  One way that could happen is if legalisation made drugs cheaper*, but this would seem unlikely.

This is one of the reasons I’m cautious about drug treatment budgets being placed within public health: a key benefit of these services – and how these have been justified politically for more than a decade – is their role in reducing crime.**  Crime is only an indirect concern of public health, in that it reflects and reinforces a lack of social capital and security, which can affect health.  It is not included in the Public Health Outcomes Framework (PHOF)***, which is the primary structure according to which public health activities will be driven.

The other reason I’ve been cautious about the substance misuse agenda being housed within public health is that the public health perspective tends to think in terms of population-wide effects and activities.  MUP is (to some extent) a classic case of this, as James Morris has pointed out.  Although it can be presented as a targeted approach, one of its attractions is that although it would only have a marginal effect on each individual’s consumption, when that marginal reduction in risk is aggregated across the whole population, the effect on morbidity/mortality is significant.

There’s been debate in the drugs and alcohol treatment field – notably from Marcus Roberts of DrugScope – about how this perspective might affect treatment services.  The concern is that, actually, a very small proportion of the population are in need of treatment for, say, heroin addiction, and targeting an intervention on a small group is counter to this approach.  (There is anecdotal evidence there’s some grounds for this concern.)  The old NTA arguments, of course, are built around on this very point: that small population of heroin users accounts for up to half of all acquisitive crime.

I’ve been concerned about this, every time I hear discussions about drugs and alcohol drift to the problem of those thousands who are drinking above government guidelines, or the seemingly growing problem of drinking amongst older people.

This is partly a turf war: I think I have a natural tendency to want to defend the areas of work I’ve been involved with.

It is partly from this insular perspective that I’ve recently thought of a reason to be cheerful.  Unfortunately, it undermines the reason to be cheerful about public health moving to local authorities.

It seems to me that there aren’t actually that many population-wide policies that can be implemented at a local authority level.  The most striking population-wide policy – MUP – would require a national policy, despite the hopes of local directors of public health.  Local initiatives – such as this one in Bournemouth – have proved fleeting, and tend to be voluntary.
Or think of putting cigarettes behind screens.  It’s hard to imagine local authorities being able to persuade multi-national operators to introduce this only in one area.

Of course, there are areas where local public health could make a difference – in fact, all those I mentioned above: transport, planning, education…  The difference is that in those areas the aim isn’t to introduce (or spend money on) public health policies; it’s to influence existing policy or activity by adding a public health perspective.

It’s harder to think of population-wide projects that are simultaneously local that public health could spend its considerable budget on.  There could be universal education and information campaigns, but it’s not clear that these have significant effects.  Rather, local public health campaigns are likely to be targeted interventions – those proposals to address older people’s drinking would would be targeted rather than population-wide, for example.  In fact, local public health teams are quite used to targeting particular areas.  For better or worse (and mostly simply for convenience) public health initiatives often focus on ready-made communities – most often working through schools, but also by targeting particular geographical areas.

So my reason to be cheerful is that in fact drug treatment could be justified in these terms; it is the targeting of a specific ‘problem’ group.

What I’m hoping, though, is that Public Health keeps that wider view and manages to have that same influence on other departments and functions of local government.

*My understanding is that there is less acquisitive crime related to alcohol addiction because this is a cheaper habit.  Of course, the flip side of this is that there’s a considerable amount of alcohol-related violent crime related to drunkenness, separate from dependence/addiction, which we might assume would fall if alcohol was less affordable and therefore less was consumed
**Police and Crime Commissioners (PCCs) do have some money that historically went towards substance misuse treatment designed specifically for those with a criminal justice connection (the Drug Interventions Programme – DIP), but this was only a small proportion of the overall spend on these services, and in many cases is unlikely to continue to be put towards treatment.
***Violent crime rates are included in the PHOF.  However, these crimes, if they are related to intoxicants, tend to be linked with alcohol and/or ‘recreational’ drugs used in the night-time economy, rather than the crimes typically associated with addiction specifically.  I should also note that treatment outcomes for opiate users are included, but only defined in terms of the proportion of those in treatment who complete successfully in the past year..  This means that you could scale back the scale of drug treatment and still maintain (even improve) performance on this metric.

Friday 9 August 2013

My unhappiness with happiness

Relatively recently, happiness seems to have come to prominence in policy discussions.  David Cameron (initially) made it a centrepiece of the Coalition Government agenda, emblematic of the ‘new approaches to government’ promised in the Programme for Government.

This week ‘happiness’ has come my way twice.  (Spoiler Alert – it didn’t make me very happy.)

First, I read Brighton and Hove’s (vaguely) new Public Health annual report.  It’s ostensibly structured around the theme of happiness, with the title “Happiness: the eternal pursuit”.

Second, I read Hannes Schwandt on the LSE Politics and Policy blog.

Schwandt was writing about how we can understand the commonly noticed dip in self-reported life satisfaction around middle age by looking at the discrepancy between life expectations and reality.  Put in cartoonish terms, we become unhappy in middle age because we realise that all those youthful dreams that kept us going through our teens, twenties and thirties are no longer achievable.  Life ain’t what we’d hoped.  By older age, though, we’ve reconciled ourselves to failure, and even predict worse outcomes than tend to happen – so we’re pleasantly surprised.  It really does pay to lower expectations, it seems.

So why does all this talk of happiness make me unhappy?

Well, there’s a number of reasons.  (Obviously.  I couldn’t be brief.)

First, we could take Hannes Schwandt’s article as meaning that, rationally speaking, we’re not very good at judging what might be thought of as our own objective health or wellbeing.  That is, it’s our expectations of the world around us and our situation that make us ‘happy’ as much as those actual conditions.

If this form of subjective ‘happiness’ is an aim of government, I’m immediately reminded of something else that makes me unhappy: fear of crime.  Community Safety Partnerships and Police forces have as their strategic objectives making people feel safer.  Now, I don’t want to rehearse arguments that other people will understand much better than me, but the point is: PCSOs (to take the example linked to here) seem to exist as much to make people feel safe as to help ensure their safety.  A key role for PCSOs, according to the Met, is ‘closing the gap between the reality and fear of crime’.

I know that an idea of ‘objective’ wellbeing might seem ridiculous, but I think it helps to highlight that this is what government is actually dealing with most of the time: a set of conditions, or proxies (such as health or income), not actual ‘happiness’.

But perhaps, if happiness is the ‘eternal pursuit’, and national wellbeing tells one more about the country than national income, then these conditions and proxies government has some influence on are means to the end of ensuring ‘the greatest happiness of the greatest number’.

In actual fact, Schwandt’s analysis seems to suggest that a more direct manipulation of people’s happiness would be more effective.  He notes that we get used to our situation (e.g. level of income) and our happiness adjusts accordingly.  I’d have thought, therefore, the most reliable way to change our levels of happiness might be through some kind of ‘mindfulness’ programme that encouraged us to live in the moment – changing how we orient ourselves to the conditions we find ourselves in, rather than altering those conditions.
That is, you could say that if subjective happiness is government’s aim, and we know that people are unhappy when their hopes and dreams are dashed, we could make people happier by making them dream smaller.  I find this pretty discomfiting though.

Paul Willis’, Learning to Labour, a classic ethnographic work of young working-class Britons in the 1970s, outlines ways in working-class boys make a virtue of the (apparent) necessity of doing a working-class job.  

As Willis puts it in the opening sentences:

The difficult thing to explain about how middle class kids get middle class jobs is why others let them.  The difficult thing to explain about how working class kids get working class jobs is why they let themselves.

In this case, having some disconnect between one’s aspirations and the most likely reality would be a positive thing, regardless of the ‘unhappiness’ involved.  Perhaps people would be right to be unhappy at doing certain jobs, or facing particular living conditions.  You might even talk about false consciousness.
This has particular implications for public health teams if we take to heart the points in this recently published article, which argues that public health hasn’t taken seriously enough the structural factors behind health inequalities, preferring instead to focus on individual ‘healthy behaviours’.

And this doesn’t need to be about a left-wing conscience.  Those on the entrepreneurial right could embrace this wish for some kind of disconnect; where else does the ‘entrepreneurial’ or ‘aspirational’ spirit so beloved of many on the right come from?  In fact, what else is aspiration but an unhappiness with the status quo?

This discomfort raises the fundamental question: is happiness really, as Brighton and Hove’s public health team tells us, ‘the eternal pursuit’?  Or perhaps more importantly, should it be?

And in turn, this raises the more fundamental question of, well, what do we actually mean by happiness?

On this, I’m a bit torn.  ‘Happiness’ could be defined in a hedonic way, as pleasure, and this would fit with the fact that I’ve always said that I’d rather be a happy pig than an unhappy philosopher, and I think that’s probably still true to an extent.  It’s what lies behind some of my defences of ‘binge’ drinking: I don’t like the idea of ‘higher’ and ‘lower’ pleasures.  (I know that’s not a serious philosophical argument to say I ‘don’t like’ the idea, but it’s one of the levels at which I’m responding.  The other is Bourdieu.)

Of course we might mean something more like Aristotle’s ‘eudaimonia’, which I would approximately translate as ‘fulfilment’.  This sort of concept could be compatible with the Millian preference for unhappy philosophising.  It could also come pretty close to the Protestant Ethic, whereby we praise God by working hard to fulfil our potential in the God-given skills we’ve got.

In any case, whether in Aristotle or Mill, there’s an understanding that quite what this means might vary from person to person.  Moreover, there’s various ‘pleasures’ we’d need to balance (the ‘binge’ against the hangover).  So whether we mean pleasure or fulfilment, if ‘happiness’ is going to be the key duty of government, we probably ought to have a think about what goes into the concept.*

However, in the case of the Brighton public health work, we don’t need to have this debate.  It turns out that all the basic form of analysis is the same as previous years, and ‘happiness’ is just a way to structure a discussion of familiar stats on STI incidence, drug-related deaths, numbers of opiate users, prevalence of smoking during pregnancy and so forth.  It just so happens that all these things that public health teams have always cared about fit neatly with ‘happiness’: people who are less promiscuous, drink less, take drugs less often and so forth so that they are publicly healthy are happier (e.g. p.47).

In this way of presenting health as central to happiness, the Brighton report isn’t too far from David Cameron’s point early in the introduction of the ‘happiness index’, when he admitted that he would be concentrating on economic policy, because without money people wouldn’t be able to do the things they enjoy.

Or is it the other way round?  On page 4 of the Brighton report the suggestion is that ‘positive emotions’ make you healthy, and that’s why we should be encouraging ‘happiness’.  By this reasoning, happiness is a means to an end – public health.

Either way, I can’t really see that using the concept of ‘happiness’ helps us understand the issues any better.  Is health a good in itself?  Is community?  Or do we need to explain that people are ‘happier’ with them?  Rather than them enhancing my wellbeing, I think I’d start to find community and religion a bit depressing, actually, if the reason I was participating was to squeeze a few extra years out of my life.  (Now that really would be the instrumentalism in friendship that Winlow and Hall talk about.)

So, bluntly, there’s no clarity around what ‘happiness’ means.  I’d go as far as to suggest that ‘happiness’ is simply a way of obscuring genuine value judgements and balancing of competing claims – and that this sort of use raises more questions than it answers.

In fact, this is precisely what the Director of Public Health says about the report – as a boast.  He claims that readers will be ‘relieved’ (not ‘happy’?) that the report contains more questions than answers.  Personally, I’d like a few more answers.

*I could at this point turn this post into one of my usual complaints about how politics doesn’t focus enough on fundamental values and aims, with debate being conducted at the level of ‘we like good things’, where ‘good’ has been so emptied of content that it’s impossible to really disagree.  Then suddenly we move onto a debate about ‘what works’, as a rhetorical device to present as unquestioned what is actually a value judgement plus a compromise between competing interests, as a policy decision always is.