Thursday 30 October 2014

On the merits of blanket bans

This morning there have been two reports released by the Home Office: one on ‘legal highs’ and one on broader ideas of drug regulation.  I was asked to comment on these by Radio Solent, and I thought I’d post some quick thoughts here.  (At the time of writing, the full reports weren't available; only an embargoed press release with some quotes that I'd been sent.)

This isn’t a comprehensive response, but it did get me thinking about drug regulation more generally – a topic I’ve touched on before here and here, for example.  You can listen to one of the interviews in full here (with me starting at 2mins 50secs).

What’s being proposed is some form of blanket ban on ‘legal highs’, as opposed to the reactive banning done at the moment, through Temporary Class Drug Orders, and then adding substances to the list within the Misuse of Drugs Act.

The first advantage of this sort of blanket ban would be consistency with other substances.  At the moment, problems emerge by virtue of the special status unwittingly granted to ‘new’ substances.  People may be tempted to choose these over more established substances, which isn’t a great idea because everyone – from users to medical professionals – knows less about them compared to more established drugs.  Also, and this is something that was put to me by an interviewer yesterday, the apparently ‘legal’ status might be introducing certain people to drug use who wouldn’t otherwise consider it.

This second point isn’t necessarily a problem, unless that drug use is seen as dangerous and/or immoral.  However, that brings us back to the first point, which is that on balance I’d rather people were using cannabis than ‘synthetic’ cannabis, for example.  The advantage of a blanket ban is that, setting aside the detail, it sends the message that these substances aren’t endorsed or legal – and that’s one of the key potential problems with the current inconsistency: even where these substances are now illegal, they’re still marketed of and thought of as ‘legal’, and therefore (I’d suggest) at some level safe and endorsed.

Of course, the reality of the policy may prove problematic: will the government really be able to enforce a ban, and how will that affect research into new drugs and chemicals?  (Although the government has said before that controlling substances doesn’t inhibit research, I’m sure David Nutt would have a different view.)

We can predict pretty confidently that in reality, the government won’t be able to enforce a ban any more than it’s already able to enforce bans on use of heroin, cocaine, cannabis and any other illicit substances – particularly with the emergence of the ‘Dark Net’.

And here’s where the other report comes in.  That’s a review of evidence on how national drug policies relate to levels of use and harm.  That is, whether decriminalising use on the one hand, or introducing harsh penalties on the other, can change a country’s levels of drug use by.  From my sight of the press release scan, it looks like there isn’t really much in it: the harms depend on other factors.  As the report puts it: “We did not in our fact-finding observe any obvious relationship between the toughness of a country’s enforcement against drug possession, and levels of drug use in that country” (p.47).

In some ways, this is an argument for a sort of natural conservatism: why change the regulations, given that they’re irrelevant.  (This is interestingly not the minister’s take.)

I’m actually more interested in what the publication of the report says about the possibility of mature policy debate in this country.  Drugs policy is an area where thinking is not clear – or at least not generally conveyed clearly in public debates.  The report itself falls into this trap, solemnly declaring that we should have policy based on ‘evidence’ and talking in favourable terms of treating drug misuse as a health problem rather than a criminal one.

But these sorts of statements are close to meaningless in themselves.  As long as these drugs remain illegal, drug policy will always be a criminal as well as a health matter – and much of the criminal issues relating to substance wouldn’t be affected by decriminalising possession: if you still need to steal to feed your habit, I can’t see how that’s going to change by decriminalising the act of possession.

And evidence – as I’ve said before – doesn’t tell you what policy to implement.  That’s based on moral and political principles, and will be the result of a trade-off.

The advantage of this report, and the debate today in Parliament, is that they might actually open up some genuine debate about those aims and principles.  When Norman Baker says that policy should be based on evidence, this isn’t quite the right phrase – but there is definitely wrong with policy debates around drugs.  I think ‘legal highs’ (and e-cigarettes) could be the most important and interesting things to come along in recent years to promote an open debate that really gets to the root of what government should be interested in when it comes to psychoactive substances.

As Virginia Berridge points out, there are bound to be historical accidents and anomalies that shape approaches to different substances, but at the same time it would be nice to feel that there is conscious deliberation going on and to have some open debate about what makes alcohol, tobacco, coffee and all the rest different from ketamine, marijuana, heroin and all those other substances that the government has declared to be unacceptable.

So far, the conversation has only been about decriminalisation, and that’s where advocates of a more liberal policy would have to make a choice: is this a sensible first step in the right direction, or does it endorse what is fundamentally an unjust and unworkable system?  (You can see Steve Rolles and Julian Buchanan go over this ground pretty much every day on Twitter.)

Of course, one thing we often forget in these debates – and I haven’t touched on yet here – is how harms from drugs don’t only relate to users, but also producers and distributors of drugs.  That is, one of the biggest problems of making the drugs trade illegal is not the users in the UK, so much as the lives of those in producing countries, where crime undermines the state (think Mexico or Afghanistan), or those involved in production in the UK, who are often victims of trafficking.  It’s a great shame when this is ignored in favour of a somewhat parochial debate about UK heroin or cocaine users.

However, it’s not often I feel optimistic about policy – but today I’d rather focus on the positive (if only to distract from my tiredness at having got up stupidly early).  If a government can raise these issues shortly before an election, then surely there is hope that we can have that grown up debate, which would be a good thing regardless of your views on drug use.

Friday 3 October 2014

Medication and Recovery - Magic Pills and Methadone

This week there’s been a lot of media fanfare around the ‘magic pill’ that’s going to save thousands of ‘mild alcoholics’.  I’m not usually in favour of putting things in quotation marks, but in this case it’s almost obligatory because the fanfare is quite clearly over the top.

I don’t particularly want to write about the weaknesses of this approach; that’s been done very well by Niamh Fitzgerald and Matt Field here.  Also, although it’s tempting, I don’t want to analyse all the misunderstandings behind articles such as this by Hugh Muir in the Guardian.

What I am interested in is what the fervour says about how public debate around alcohol and drug use is able to sustain apparent contradictions in understanding different substances.

For the past few years – at least five – the field of drug treatment in the UK has been grappling with the issues of ‘medication’ and ‘recovery’.  What does it mean to ‘recover’ from a ‘substance misuse disorder’ (and what is one of these anyway?) and what role can and should medications like methadone play in that process?

This is the point of the much referenced Strang Report, called, in fact, ‘Medications in Recovery’.  (Though as I said to someone who sat on the panel – though I didn’t know at the time – that was all a bit of a fudge anyway, since although we can all agree that ‘recovery’ is a good thing, the word itself only begs all the crucial questions that still need answers.)

Anyway, the upshot of this great debate is an increased emphasis on the importance of psychosocial interventions – or ‘talking therapies’ as they’re more commonly known – in fostering recovery, and a concern that long-term medication doesn’t really amount to ‘full recovery’.

To add to this feeling of moving away from medication, the trends in drug use – and therefore need for treatment – suggest that fewer people are using opiates like heroin, and there’s an increase the relative importance of drugs like ‘legal highs’ (or ‘new psychoactive substances’) that don’t fit a model of substitute prescribing in the model of methadone for heroin – in fact they often don’t fit any model of prescribing at all.

I’m not saying the shift in emphasis away from methadone maintenance is right or wrong – or that the way this has played out is the same everywhere – but the key point is there’s been a crucial shift in emphasis in public policy debate.

This shift actually ties in quite neatly with broader trends in medical policy so emphasise ‘social prescribing’ rather than imagining medicines can sort everything.  Of course this opens up a can of worms as to whether it’s fair to characterise GPs as ‘pill pushers’, but this is a definite direction of travel in primary care policy discussions, only amplified by current concerns around antibiotic resistance.

You might even make links to broader public policy trends.  Methadone maintenance works on the principle that if you get rid of physical cravings for a drug, someone won’t need it, and therefore should be well-placed to stop using it.  But behavioural economics – which underpins the popular ‘nudge’ theory of public policy – reminds us that we don’t necessarily act on the basis of what we ‘need’ or what’s ‘good’ for us.

It’s in the context of this mood of public debate that Luncbeck has emerged with Nalmefene – or Selincro, as it’s marketed.

It’s worth noting at this point that Nalmefene is actually an opioid antagonist, similar to Naltrexone, which is used to treat heroin users.  That is, it blocks the receptors that give opiates like heroin their pleasurable effects on the body.  It’s precisely this sort of intervention that opiate treatment in Britain is (arguably) moving away from.

One explanation for the fanfare, then, is simple business logic: pharmaceutical companies see an opportunity in the public concern about (non-dependent) drinkers, and so manufacture a relevant product, which fits particularly well with the fact that the UK market for opioid agonists and antagonists is likely to shrink in the coming years.  A ‘pill’ that’s similar to what’s been used for opiate treatment can now be used for alcohol treatment, just at the point when the general feeling is that alcohol treatment services need to be expanded (probably at the expense of drug services designed for heroin users).

I think there’s something more to it than that, though.  This isn’t just about Lundbeck putting out a press release and there being a slow news day.  Nalmefene is genuinely more likely to find favour than similar drugs designed for people with issues with substances other than alcohol.

I think the fact we’re so interested in this ‘magic pill’ at the same time as think tanks as varied as Demos and the Centre for Social Justice talk about the importance of ‘character’ and how drug users ‘have a responsibility to work towards their own recovery’ to take ‘responsibility’ for their own recovery, and the Conservative Party announces the idea of ‘benefits cards’ for those with substance misuse issues, points to a distinction made between alcohol and other drugs.

This distinction is also infused with a notion of class – as the idea of benefit cards makes clear.  It might be worth asking whether – if the aim of these cards is to protect families from the impact of parents diverting resources ‘to feed their destructive habits’ – the same protection should be afforded those in families not receiving benefits.

Regardless of this policy question, though, there is a difference in who is expected to show self-reliance and not be medicated by the state, and who we think might benefit from the ‘magic pill’.  The latter are drinking half a bottle of wine a night, apparently – and the very choice of drink to illustrate the problem says something about the way it is understood.

If we think back to the idea that the shift away from methadone maintenance might dovetail with the principles of behavioural economics, in fact the opposite could be true: you could argue that a pill to deal with cravings fits perfectly with the idea that we’re weak-willed, irrational beings – we can’t be trusted to moderate our drinking simply through reason and self-control, so we need a pill to do it for us.

The question is: who gets a magic pill and who has to demonstrate self-reliance?  I’m not sure the answer doesn’t depend on the substance being used and the status of the user.