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.