Wednesday 29 March 2017

Is drug policy about drugs?

This week, I’ve been at a mini-conference to discuss prohibition through different periods of history and across different countries and societies.  Although I did (part of) my first degree in history, anything I write now is more based on what ‘I reckon’ rather than any genuine knowledge, historic or current.  So it’s not clear what I was doing there, but they let me in anyway.

(I should say at this point, as I did when I wrote about the original conference, that this is an amazing group of academics, and there’s a load of fascinating work going on at Warwick University more broadly.)

My contribution was born a year ago as a response to the 2016 Psychoactive Substances Act.  Unsurprisingly, at that point (and now), it was hard to find too many academics in history or social policy prepared to defend the Act.  So, being the attention-seeking contrarian that I am, I saw my role (or my way of getting a paper accepted) as being to be a bit more positive about the Act.  I suggested that it could be a catalyst for change in drug policy, as it reframes the debate from being about harm to being about psychoactivity itself.  But that’s a post I’ve kind of already written (though I can write it much more clearly, and will do sometime).

So what I want to do here is to reflect on what we were trying to do as a whole.  The idea was – and is – that we can usefully say something about the idea of prohibition through the ages.

But I was constantly reminded of a paper I saw at the wonderful ADHS conference a few years ago.  There, Lauren Saxton talked about how alcohol was understood to lead to infertility amongst women in France in the nineteenth century (because that was their major national concern), whereas at the same time, with the same substance in Britain, we were concerned that alcohol was leading women to have more children than they should do.

The point being: alcohol (or any other ‘drug’) has a meaning and set of concerns that are hugely dependent on the wider context.

So what’s that got to do with prohibition?

Well, hearing these accounts from France, Indochina, Mexico, Russia, America, Portugal, as well as the UK and the international community more generally, I started to think about how alcohol or any other drug offers something of a lightning conductor for any other concerns the public might have, be they in relation to race, gender, class, nationality, religion, productivity, industry, modernity, or anything else.

In some ways, use of morphine in the late nineteenth and early twentieth century could be seen as rational, pure, clean and reasoned, with the use processed ‘white drugs’ (like heroin and cocaine, as well as morphine) administered with precise dosage using the technical innovation of the syringe.  This was what Christopher Hallam was telling us the ‘bright young things’ of the interwar period were doing – elite, well-educated, white aristocrats.  ‘Brown drugs’ were less processed substances like hashish and opium, perhaps seen as ‘dirty’ and were more associated with the working class or ‘foreigners’ like Chinese immigrants.  (The white/brown binary here really is pretty transparent.)

But others, like Susannah Wilson, noted that in some cultures and periods, that scientific/natural binary doesn’t always have ‘science’ on top.  Of course, doctors can use it to defend their own use, as they did in nineteenth century France, but the precision and technical approach to drug use can be seen as new and frightening.  Soon, you get onto a discussion of the optimism and fear that equally surrounded ‘modernity’.  Is change exciting, frightening, or both?  Are ‘natural’ ingredients better than chemically pure, processed ones?  You’re probably thinking that it depends on who you are, what you’re doing and what you’re trying to achieve.  And so it is with drug debates.

Similarly, the idea of prohibition can symbolise any number of things.  It can be, as Mark Lawrence Schrad argued, an opportunity for emerging nations (such as Turkey, even when ruled by heavy drinker Ataturk) to expel foreign industries and express a new anti-colonial identity.  Or it could be an opportunity for the Protestant Ethic to express itself.  (And I should reference the work of Henry Yeomans at this point, as I didn’t do in that post.)  Or, in the early twentieth century, it could be a way for a nation to show it was part of the international club, which Cecilia Autrique noted was part of Mexico’s motivation in developing drug policy in the early to mid twentieth century.

Alternatively, rather than being anti-colonial, prohibition has been justified by discourses of anti-orientalism (that drug use is somehow characteristic of ‘weak’ nations like the Chinese, or Arabs, or whatever culture is viewed as negative in the time and place in question).

But even here, things are complicated.  Aro Velmet explained that the same forms of drug use were seen as appropriate to French Indochina in the early 20th century, because of the culture and climate – not just for people from that culture, but for French people living and working there – but inappropriate if they were continued on returning to France.

So amongst all this I started to wonder whether there was any coherence at all.  Notably, as James Nicholls has pointed out, there’s no straightforward position on the issue of ‘alcohol’ that can be produced by reference to even the relatively narrow definition of nineteenth century liberalism.  JS Mill argued that it wouldn’t be real freedom for us to abstain from alcohol if it was just what was required.  And yet TH Green maintained – invoking the same argument that led Mill to reject slavery, that we shouldn’t be given the opportunity to become dependent on alcohol – we’d be better off if alcohol was never available.

And as Mark pointed out, this is a more nuanced debate than we often acknowledge: the key organisation in the US was the Anti-Saloon League, rather than the Anti-Drinking-at-your-own-pace-at-home League.

So, given all our discussion, is really anything linking these themes at all?  I’m reminded of my concern about whether there is any point in trying to develop an ‘alcohol’ strategy.  ‘Alcohol’ or ‘drugs’ or ‘prohibition’ might be a lens through which to look at society, but what we end up actually looking at are the familiar themes of politics, identity, and so on.  It’s no surprise that a discussion of drug policy in the nineteenth and twentieth centuries ends up as simply a discussion of racism, anti-colonialism, nationalism, gender, class, and so on – the ‘fundamental’ issues of societies in that period.

So is there any point talking about ‘prohibition’ as a general concept (or more importantly as a useful academic concept)?

Well, only in as much as James Nicholls suggests alcohol is a useful lens through which to understand how people think of and enact liberalism (in principle and in practice).  But maybe what that means is that there’s not much point studying the phenomenon of prohibition in itself, or trying to understand what motivates people to ‘prohibit’.  Perhaps, just as with ‘alcohol’ and/or ‘drug’ strategies, the ‘take-home’ point should be that we need to think about what these substance-specific ideas tell us about life more broadly.

So, in answer to the title of this post, I’d say no, ‘drug policy’ isn't really about ‘drugs’.  But it's worth pointing that out. And as ever, I look forward to a more open, honest discussion.  And I’ll be writing again soon about how the 2016 Psychoactive Substances Act can be part of that more open and honest discussion.

Tuesday 21 March 2017

Alcohol, productivity and morality

Work has been pretty busy lately, so I hope readers will forgive me posting about what might seem to be ‘old news’.  But, as anyone who’s studied policy relating to alcohol or other drugs for any length of time will surely agree, the issues tend not to go away, but cycle round to be viewed in a new light.  And it’s precisely that sense of history that’s prompted this post.

The blog started with a neat ‘parable’, credited to economist Frederic Bastiat, of a shopkeeper whose window is smashed, who tries to look on the bright side by saying that at least replacing the window will keep the glazier in business.  The point is, of course, that the shopkeeper would have been able to spend the same money on something else had the window not been broken, and kept maybe a cobbler in business while seeing a tangible improvement in his own life.  And similarly, it’s claimed, we shouldn’t worry about harming the economy if we reduce alcohol consumption or even the money spent on alcohol, as this can simply go on something else.

My initial reaction was to take issue with Aveek on two points.  First, whether the alcohol industry is really anything like the glazier in the story.  Isn’t the role of the glazier played by the police, NHS, or alcohol charities, repairing damage caused by alcohol?

But I suppose if the alcohol industry really is the glazier, then we’re not suggesting that all windows/alcohol are bad, or a waste of money; simply those where the spend is the result of some kind of damage.  By my understanding, the analogy would then run that we shouldn’t be vandalising (or consuming somehow irresponsibly), but windows/alcohol can be useful, beautiful, and part of a healthy economy.  Windows in themselves aren’t undesirable or immoral.

And this got me thinking: maybe I’m over-thinking this.

Aristotle! if you had had the advantage of being ‘the freshest modern’ instead of the greatest ancient, would you not have mingled your praise of metaphorical speech, as a sign of high intelligence, with a lamentation that intelligence so rarely shows itself in speech without metaphor, — that we can so seldom declare what a thing is, except by saying it is something else?  (Eliot, The Mill on the Floss)

So let’s aside whether the alcohol is like glass, and focus on the second area where I was going to take issue with the argument: that economics has anything to do with this at all.

Setting aside Aveek’s personal position, as everything I’ve read by him suggests he’s open, honest and sincere, I started to wonder how well this argument fitted with whatever corporate view the IAS might have.  I just wasn’t convinced that their hearts would really be in it.

I started to think of why I set up this blog in the first place: frustration at the disingenuous nature of much public policy debate in the two fields I’ve worked in.  Drug treatment was justified by painting ‘addicts’ as dangerous, and higher education funding was justified by boosting economic productivity.

Neither actually gets to the heart of why I think these things should be supported.  Drug workers haven’t come into the field to reduce crime, and most academics don’t see their vocation as being to enhance graduate ‘employability’ or develop a productive ‘spin-out’ company.

Moreover, from a pragmatic point of view, I’d worry that when economic times get hard despite the continued existence of Oxford University, or acquisitive crime becomes less of a hot-button topic, the power of those narratives falls.  You haven’t won the fundamental argument that these policies are a ‘good thing’.

Similarly, I wondered, was economics really why the IAS opposed alcohol, or certain forms of alcohol consumption?  What if the data shifted and suggested that alcohol was a genuine boost for the economy?  (That’s certainly a tactic being used by people seeking cannabis policy reform.)  Would that change their minds?  Of course not.  So I was going to write about how the IAS is using economics disingenuously to justify what is really about morality or public health.

But then I realised I was doing exactly what I complain about other people doing: simplifying the argument into an either/or, or looking for the single factor that ‘explains’ their position.

I stepped back, and started to think about how, in reality, we tend not to separate economics from morality.  Whether it’s debates about benefits or executive pay, the argument can rarely be boiled down to a question of objective market factors.

And the same applies to this issue of alcohol and morality, health and economics.  There’s a long history of ideas of productivity being linked with discipline, morality and temperance – just think of the Protestant Ethic and the strong influence of non-conformists in the temperance movement.

In fact, the IAS has its roots precisely in that tradition, being an outgrowth of the UK Alliance, itself founded by non-conformist advocates of temperance.

(I’m hoping I don’t get pulled up too much on my knowledge of Victorian religion and the temperance movement – I’m just making a broad point.)

So my point – apart from illustrating how I argue against myself in my own head – is simply to note how several motivations and perspectives might well come together at once.  When we think about productivity, we might well be thinking about morality too, and that might be tied up with an idea of a healthy, active body as much as an economically productive mind.  It really is a coherent vision of how we could all be fitter, happier and more productive if we only drank less.

The only problem with this is that, precisely because the worldview is coherent and consistent, it challenges the idea that these debates about economics are somehow objective.  This is, as ever, a discussion about ‘the good life’, to return to Aristotle.  And, inevitably, we won’t all share the same vision of what that is.

Monday 13 March 2017

Stigma and drug regulation

Lately I’ve been thinking a lot about stigma and words relating to substance use.  Carl Hart recently wrote a piece arguing that understanding ‘addiction’ as a ‘brain disease’ contributes to social injustice, and when NACOA recently launched a manifesto for ‘children of alcoholics’, the write-up by Alcohol Policy UK got me wondering about that much debated word ‘alcoholic’.

Stigma is often cited as a reason to introduce drug reform.  It might be unfair, but sometimes I get the feeling – as Julian Buchanan suggests in that post I just linked to – that some reformers think stigma itself would be undermined by legalisation.  I think, aside from ignoring the experience of alcohol and ‘alcoholism’ in particular, this misunderstands what stigma is and where it comes from.

Plenty of research on drinking – including my own – suggests that there is huge stigma around certain forms of drinking behaviour, both amongst drinkers and policymakers (local as well as national), even though (or perhaps because) alcohol is legal.

I used to think (when I was working solely on alcohol policy) that it was the legal status of alcohol that brought out particularly odd, self-deluding arguments, as we each try to contort our reasoning to claim that it’s not our own drinking that’s problematic, but someone else’s.  We can’t condemn people for drinking per se, so we have to look for something else to dislike.  So if the government says drinking 14 (or even 21) units a week is a bad idea, we counter by pointing out that we haven’t caused any nuisance or engaged in any crime, unlike some people, and we spread out our units across the whole week.  But others would use precisely the same definition to argue that, even though they drink pretty heavily on one night of the week, they’re not drinking that much per night on average, and they certainly don’t drink every day, which would be a sign of a problem.

It’s true, this feels odd, and I got tired during my research of hearing people say that they didn’t drink to get drunk, but noting that this did – just coincidentally, obviously – happen when they went out with their friends.  I think at some level I felt this was dishonest: if you don’t drink to get drunk, but engage in the same practice almost every Friday night, and it always happens when you do, then surely you do intend to get drunk at some level?  And what’s wrong with admitting this?

But actually, having looked at drug policy, I can see this in a different light as somehow more open and honest.  Government and drinkers alike don’t actually condemn physiological intoxication, except where it relates to your ability to drive a car.  How could they, given this is seen as an inherent property of alcohol, which is legal?

(In fact, they could quite easily: through our weird attitude to ‘rationality’ and laws such as serving people who are drunk, drunk and incapable, etc.  But let’s set that aside for just a moment.)

When people deny that a certain level of consumption is problematic in itself, and that really we should care about behaviour and the setting of this, they are quite honestly getting to the heart of the matter.  It’s perfectly honest to say what’s actually a problem is violence, or disorder, or even simply being immodest.  What would actually be dishonest for most drinkers would be to suggest they’re offended by some ‘inherent’ or ‘objective’ property of a substance, or intoxication in itself.

But that’s precisely the basis of much drug policy debate: not just that drugs are ‘dangerous’ but that they are somehow morally questionable in themselves.

We like simple arguments: x causes y.  Famously, we’re not good at understanding the idea of risk and uncertainty, let alone accurately judging it and responding accordingly.  This is why debates about alcohol guidelines get lost in the mire of whether there is a J-curve of risk, and reports suggesting one way of dealing with harm related to cannabis get sucked into a fruitless debate of whether cannabis can ever be harmful at all, even when both sides are deliberately trying to avoid it.  (I was going to link to another thread on Twitter at this point, but I see it’s been somehow deleted – certainly not by me!)

And so we like the idea that we can define ‘drugs’ in general – or even specific substances – as dangerous (or not), or at least on a spectrum.  And Public Health campaigners like the idea that alcohol is inherently problematic: it’s no ordinary commodity and there’s ‘no safe level’ of consumption.

I appreciate that these are partly campaigning tactics: it’s easier to state that something is inherently ‘bad’ rather than look at nuances of social and cultural context – drug, set, and setting, to use some out-of-date terminology.

But the reality is unquestionably more complex.  There simply aren’t ever fixed, objective characteristics of a substance in any way that’s relevant for policymaking – and I don’t just mean the panic around crack cocaine that Carl Hart (amongst others) has so clearly debunked.

This is where the idea of alcoholism or addiction as brain disease is relevant.  Carl Hart, as I mentioned, sees this concept as perpetuating social injustice.  The point is that according to this theory, the fundamental issues of ‘addiction’ are due to how a chemical interacts with the brain.  This is understood as a (not very) simple ‘fact’ of neuroscience.

If that’s how addiction is understood – or what it’s reduced to – then as Hart points out, this means the issue (and therefore the ‘solution’) either lies with the substance or the brain.

For the past century, we’ve tended to see the solution regarding alcohol as being to address the brain.  Or, rather, the specific brains that have a problem with alcohol.  This is still the dominant view of addiction or alcoholism today.  We talk about certain people as having ‘addictive personalities’, and most people’s view of alcohol would be that controlled (or ‘responsible’) drinking is possible – but not for everyone.  ‘Alcoholics’ are effectively defined as the people who can’t simply have ‘one or two’ drinks.  As Mark Gilman puts it, some people ‘have the spots’.

But for ‘drugs’, we’ve tended to take the opposite position: that the danger is in the substance itself, not just that certain people are susceptible.  That’s certainly a good rationale for keeping drugs illegal: if one hit of heroin, crack or methamphetamine can lead to addiction (and sensible, well-educated, scientific people have insisted on this when I’ve suggested otherwise), who would allow people to buy and consume it?

But the crucial word there is ‘can’.  Even if it were true, it surely wouldn’t apply to everyone.  But as soon as we admit this, we have to think in shades of grey, rather than black and white, unless we simply fall back on the idea that some people ‘have the spots’.

Now this blog is really here as a way for me to write what I ‘reckon’, without having my argument fully formed or evidenced as I’d need in a professional or academic context.  And as I thought – reckoned – about this idea of addiction-as-brain-disease, another currently popular idea came to mind: that policy regarding a range of substances is converging.  Virginia Berridge most notably, but also Mark Monaghan and Henry Yeomans (this is the paper I’m thinking of), have written persuasively about how several jurisdictions seem to be categorising substances like cannabis and tobacco in similar ways – legal, but highly regulated – and this is related to a convergence in how we think about them: as legitimate consumption choices, but with some risks attached that merit the state getting involved.

It’s easy to attack someone on the simple basis that they use a particular ‘drug’, of the use of that substance is somehow inherently ‘wrong’.  However, if this convergence thesis is accurate, and we are increasingly seeing caffeine, nicotine and alcohol and other substances as ‘drugs’ in some sense, it becomes harder to maintain that simple but comforting fiction that ‘drugs are bad’ (mkay).

And bearing in mind our tendency to like  clear arguments and positions, if it’s not the substance that is the source of the problem – an assumption which can’t be so easily sustained if ‘we’ use ‘drugs’ like caffeine and alcohol too – it must be the person; the ‘addict’ with a ‘diseased’ brain.  These substances don’t cause everyone problems, so we should look out for the specific people who are likely to find them difficult to manage, probably due to some genetic predisposition.

This is remarkably similar to the idea of condemning young drinkers who don’t know their limits, rather than identifying alcohol or licensing policy as the issue.  (I’m not saying one of these is wrong or right; just pointing out that they’re different analytical approaches that lead to different policy ‘solutions’.)

And in both cases, whether relating to ‘drugs’ or alcohol, as Carl Hart suggests, we could do with a bit more social context to understand why some people are more likely to face problems than others.  Might this have something to do with wider social factors like housing, employment and wealth?

This is a potent reminder that policy ‘convergence’ and the call of ‘legalise and regulate’ won’t address stigma, which comes from somewhere deeper.  In fact, as the stigma surrounding particular substances reduces, you might even argue that the stigma attached to individual ‘flawed consumers’ could increase, as they bear the blame for running into problems or consuming them in the ‘wrong’ way, rather than being able to blame the substance itself.

The bigger task, then, is to try to inspire more nuanced thinking, as Carl Hart suggests, that moves beyond seeing problems as either the result of a ‘drug’ or an ‘addicted brain’, and looks at both of those in the wider context of the society we live in.  I hope this blog contributes something at least to that idea.