Tuesday 14 January 2014

Beyond a ratchet model of drug policymaking

Today I read a ‘for debate’ academic article published in Addiction: Alex Stevens and Fiona Measham arguing that current British drug policy operates according to a ‘ratchet’ process, whereby the tendency is for restrictions and controls to be applied, and this is a one-way street as the restrictions are (almost) never downgraded.

Stevens and Measham obviously feel the need to justify the article, as they acknowledge that many people will feel the argument is so obvious it doesn’t need an article dedicated to it.  However, it might seem necessary in light of the reclassification of cannabis downwards (before it came back up) and the coverage of Peter Hitchens in the media arguing that there has been no war on drugs.

The analogy of the ratchet is chosen because (in general) the argument is that once action is taken, it’s unlikely that it will be scaled back later.  However, in itself this is not negative – or perhaps even worthy of comment.  If we believe in a particular approach or action that is being ratcheted up, we can see this as progress in a consistent (and positive) direction.

The reason Stevens and Measham see the ratchet as a critique is the direction policy is heading in: towards control and prohibition.  This, they suggest, is not an effective evidence-based approach for reducing drug-related harm.  That is, the ratchet trend direction is more important than evidence, which is only used (through ‘absorption’) when it fits the pre-determined narrative and policy direction.

This direction of travel is towards something Stevens calls ‘toughness’.  It is more important for policymakers to be seen as ‘tough’ than for them to demonstrably reduce harm.

There are two key elements to the article, then.  First, the ratchet model of policy development.  Second, the idea of ‘toughness’.

Importantly, neither of these implies or explains the other, so while this might be an accurate description of UK drug policy I’d suggest it doesn’t get us any closer to understanding why the policies are developed in the way they are.  (To be fair to the authors, they don’t suggest they’re trying to do this in what is of necessity a very brief article.)

Answering this question of why UK drug policy formation follows this process would, like the distinction between ratcheting and toughness, probably require two sorts of approaches.

First, on the ratchet concept one would need to think through ideas of policy competition.  Maybe there’s some inflation-style model of policymaking, whereby political parties outbid each other and find it hard to step out of the terms of debate.  I don’t know much about these sorts of models of policymaking – that’s something I’d leave to the likes of Paul Cairney and Vittal Katikireddi.

But as I suggested, I don’t find the ratchet model something that would necessarily need changing in itself; it’s what we’re progressing towards that might be questionable – and in the field of drug policy this seems to be an emphasis on policy methods (prohibition, restrictions, criminalisation of new psychoactive substances) rather than policy aims.*

So we need to think about why these policy methods are attractive, even if they’re not really reducing harm.  And here we get to the bit of policy analysis that I find fascinating: attitudes to drugs, pleasure and health.  I would suggest that the fundamental principle driving the direction of travel is the view that substances seen to alter mind or body are considered suspect and unnatural – particularly when they relate to sensory pleasures.  This, I should point out, is something I think Stevens and Measham would agree with – Fiona Measham has actually written a book chapter entitled ‘The criminalisation of intoxication’ and Stevens has blogged about the morality underlying Peter Hitchens' claims regarding evidence.

Of course there are other elements to this trend – and there may be mileage in thinking about what Stevens and Measham refer to as the ‘thoughtworld’ of policymakers.  Civil servants, it could be argued, are likely to recommend policy approaches that have a significant role for government (and thus civil servants), whether through conscious calculation or, perhaps more likely, simply familiarity.  Control or prohibition might be such approaches – but then it would be hard to argue that legalisation and regulation of drugs like alcohol and tobacco doesn’t provide significant employment and funding to the state.

So, I’d suggest the ratchet framework doesn’t actually get us that much closer to the stated aim of the article: to ‘help us to use evidence and public deliberation to fit drug policies more effectively to the prospects of reducing harms’.

The key battleground is really over the definition of these ‘harms’.  Peter Hitchens might see himself as a lone voice, but there remains an assumption – at least in terms of what it is acceptable for politicians to say and do publicly – that intoxication in itself is harmful.  Until that position is challenged head-on I can’t see the ratchet mechanism changing.

*This isn’t to say that governments are genuinely committed to enforcing prohibitionist policies.  Peter Hitchens could be said to have a point that much of drug policy is more about rhetoric than effects – and in fact that’s something Stevens and Measham might agree with.

Thursday 9 January 2014

MUP as a lightning conductor

New year, same old alcohol politics.

Just as I was thinking I hadn’t posted for a while, as this blog is generally responsive and there hadn’t been many alcohol news stories worth thinking about (I’m not touching Dry January – read Pete Brown if you want anyone’s opinion), we all start talking about minimum unit pricing again.

I can’t quite bring myself to address the points people have been making, whether it’s Sarah Wollaston in the Telegraph, Anne Perkins on the Guardian website, or the Dick Puddlecote blog.  There’s a ridiculous claim that the Sheffield modelling is ‘deliberately contrived junk science’, and on the other side it’s suggested that Diageo shouldn’t sponsor a cocktail lounge at the Tory party conference – as if having a free drink might make a serious politician beholden to the alcohol industry.

Being the academic I (like to think I) am, I’m more interested in the fact that, yet again, we’ve focused on MUP.  This particular policy seems to have been the lightning conductor for all the concerns and debates around alcohol policy in the last few years.  After an interesting discussion on Twitter a few months ago, thinking about how the coverage and debate around MUP has been different in Scotland as opposed to England, I thought I might post something on here about why MUP has been so important and divisive in the public policy debate.

The first and most obvious point as to why it has caught the imagination is that the idea of a single, relatively straightforward solution is always attractive.  MUP has managed to capture the imagination as the solution to the alcohol ‘problem’.

Of course, it can’t be the single universal solution, and there isn’t actually an ‘alcohol problem’ – if there is any problem, there’s certainly more than one: crime, nuisance, acute health harm, chronic health harm, addiction, and the list goes on.

In fact, each one of these issues isn’t a single ‘problem’ in any case.  Along with others, I’m sometimes guilty of suggesting that addiction is no respecter of class and backgroundThis is certainly questionable when we look at what factors might make us think of particular forms of substance use as substance use disorders, and who might be most likely to achieve recovery, but more than this, not everyone’s ‘addiction’ is driven by the same factors, and some people (like it or not) may not feel they will always be an alcoholic – and may even feel comfortable enough to drink again.

MUP raises all those old issues around addiction, health, drunkenness and so on, but without them being explicitly named – and that’s why the debate focuses so much on this initiative, because it somehow is able to channel whatever concern about policy any person has.

As I’ve said any number of times before, public health tends to operate at a population level, and MUP can be seen as a policy that does this: it is (ostensibly) universal, rather than being targeted at particularly problematic individuals.

Although MUP can also be seen as targeted – David Cameron was keen to say it was an initiative to address ‘binge’ drinking, while the Sheffield research suggests it will hit (or benefit) the hardest drinkers hardest – the key point is that it targets the substance, not individuals.  This is one of the key reasons it excites public health campaigners and worries those whose business it is to sell alcohol.  ‘Alcohol is no ordinary commodity’ is a mantra of the public health community, and challenges the more free market view that alcohol is just another consumer product.

Thus the initiative gets straight to the two fundamental points that alcohol policy is based on: individuals’ current behaviour is irrational, and the state has a role in correcting this.

The way this is understood in England in relation to MUP can be seen as different to two relevant comparisons: Scotland, and Licensing.

It was the Scotland comparison that first interested me: I was told that in Scotland the policy debate hadn’t revolved so completely around MUP.

Although this might be the case, an analysis of the arguments for and against MUP in the media suggested that advocates for MUP didn’t often present it as part of a broader package of alcohol policy initiatives.  More importantly, though, the key context was statements regarding ‘Scotland’s heavy drinking culture’.

The article, along with other work by the same team, suggests that for MUP to be seen as appropriate, the concept of problematic drinking at a population level needs to be conveyed, rather than the current emphasis on ‘binge’ and youth drinking (which is what David Cameron did in England).

That is, the context for MUP discussions is possibly already more focused on population consumption in Scotland than it is in England.  Alcohol is possibly more acknowledged as problematic for all (Scots).

Where discussions around alcohol misuse are broadened out in England, the reference point tends to be simply an alternative problematic group – most recently the baby boomers, but at other times middle-class professionals.  The problem is not alcohol, but those drinking it: the middle classes who dare to ‘think they know better than health experts’.

The other difference is with licensing debates.  MUP quite clearly isn’t simply focused on the visible, night-time economy that so dominates media coverage (‘bench girl’ ends up illustrating almost every article on alcohol, or her neighbour in patterned tights – until the 2013 fashion for ‘nose in glass’).  Licensing can be – and is – framed in terms of nuisance to others, crime and disorder (and also the inconvenience to police shift patterns).  These are all factors that relate to someone’s drinking harming other people.

This is why MUP is so controversial: it’s not just about stopping me hurting other people; it’s apparently about stopping me hurting myself.

This is where the argument is attacked in terms that state either it’s my right to drink myself to death.  However, this is to look at alcohol as an individual rather than a population issue.

This isn’t just about aggregating risk – the point that not everyone is harmed by alcohol in the same way, so we shouldn’t target the alcohol, but the at-risk individuals (or nobody, as the health consequences are something of a lottery).

If I hurt myself, that doesn’t happen entirely without effects on others, however indirect.  People do not exist in isolation from a wider drinking culture, and that drinking culture does not exist in isolation from regulatory structures.

It is revealing that discussions of licensing often place emphasis on the 1915 reforms that are seen as forming the basis for the regulations that were in place until 2005.  These reforms were justified not so much in terms of reducing nuisance as ensuring that people didn’t drink so much as to be ineffective workers – and therefore hamper the common endeavour of the war effort.  That is, licensing needn’t always be a tool focused on a narrow definition of ‘harm’.  North of the border public health is now a licensing objective alongside the issues of nuisance and crime.

It could be argued that in relation to drinking public health is a misnomer: this is all about private health, and we’re not engaged in a war effort, so the comparison is irrelevant.

However, there seems little doubt that drinking styles are communicable, so perhaps rather than working with ideas of ‘passive drinking’ to suggest that drinking harms others around us in ways we don’t always see, public health campaigners might be better starting from the point that drinking is social, and that’s actually why it’s a public policy issue.  Maybe substance misuse isn’t such a non-communicable disease after all.  (Though that isn’t an original thought.)

That’s a bigger argument for another day – about the very question of whether one man is an island – but the point is that it’s not an argument that can be solved by looking at MUP as an issue in isolation.  There are broader political, philosophical and ideological questions distilled into this policy proposal, and they can’t be resolved simply by re-hashing the same old complaints about the nature of the alcohol industry or the fallibility of econometric modelling.  First off, it’d be nice to have some clarity about what problem MUP might be trying to solve.  To be honest, I’m not sure what that BMJ investigation adds…