Friday 27 October 2017

Fitter, no happier, but more productive

In the past couple of weeks I’ve not been drinking any alcohol.  This isn’t part of any grand plan; it’s just for a short period of time for some personal health-related reasons.  As I’m not generally much of an advocate for Dry January or Go Sober for October, it’s an interesting experience, which I wouldn’t otherwise have chosen.

I won’t deny that I seem to be fitter and more productive.  I don’t weigh myself, but I seem to have lost a bit of weight – which is particularly surprising given that I haven’t been able to exercise because I broke my toe three weeks ago.  And I’m more likely to tidy up the kitchen at the end of the evening rather than just leave it for the morning (or, more likely, the following evening before doing the next round of cooking).

That’s all great, but what about that third element of the Radiohead song: being ‘happier’?

Well, in some ways now isn’t the best time to ask, as work is far from perfect and my home life is facing some particular challenges (the reasons I’m off alcohol in the first place).  But actually, that’s precisely what’s been interesting about the whole experience.

Basically, I have an unusual energy and focus.  I feel a little bit like I’m back at school, working hard, being responsible and disciplined.  But, like at school, it’s not making me very happy.  And that’s because having energy and focus without a goal is worse than simply being apathetic.  You’re a conformist without a cause.  That is, for me, one of the positives of alcohol: it distracts.

For some people this is a failing from a moral perspective.  The sort of people who see substance use as a ‘shortcut’ to pleasure, which doesn’t offer real fulfilment.  Personally, I am unsure what ‘real’ fulfilment would be, given that anyone who has ever had goals knows that achieving them offers something less than satisfaction.  Life, for better or worse, goes on, as writers and philosophers throughout history have known.

For Dostoevsky, the answer to the illusory nature of achievement seems to be the love of a good woman and a bit of religion.*  And maybe, as I’ve written before, ‘just surviving is a noble fight’.

Alcohol, as used by many people, is a variant of Dory’s famous mantra: ‘just keep swimming’.  I was once warned ‘don’t think too much’, and alcohol (on the surface and in the short-term, at least) helps stop that.  To quote another 70s soft rock classic, ‘don’t let the sound of your own wheels drive you crazy’.  In fact, that’s precisely what mindfulness is intended to do, for better or worse.

And rather than just being a personal moan, I want this piece to have a broader point, linked to my previous blog post about how drug-related deaths are about more than just treatment services.

I’ve always been suspicious of the idea of ‘aspiration’ in political discourse.  Blairites offered is as a warning to anyone proposing policies that weren’t carefully triangulated and safe.  The implicit definition of ‘aspiration’ according to this approach has always seemed materialistic to me – that people want more money, or more stuff, and they’ll just stay docile if a ‘rising tide lifts all boats’.  Don’t talk about redistribution because people want to believe that someday they’ll be millionaires.  (This is usually presented as a patronising lecture from one well-meaning, middle-class, top-down politician to another, complaining that they don’t understand ‘ordinary’ [read ‘working-class’] people’s ‘aspirations’.)  And when it’s not in the hands of third way politicians too scared to talk about their actual beliefs, ‘aspiration’ as a concept is worryingly used to explain poverty as being caused by a lack of aspiration.

But to bring this back to my moan, I think what I’ve found difficult is that without the distraction of alcohol (and I mean the trips to the pub as much as the actual substance – given that this is about ‘set’ and ‘setting’ as much as ‘drug’) I’m lacking ‘aspiration’.  My increased fitness and productivity is without purpose, as there’s too much other stuff going to enable me to feel any happier.

This isn’t a blinding insight, and I certainly don’t want this to read like a ‘poor me’ post.  I’m well aware that there are plenty of people around me who are worse off.  My point is simply to note that a lack of ‘aspiration’, or visible, achievable life goals, is pretty common and not clearly related to substance use.  The fog does not magically lift and a ‘purpose’ appear; and even if it did, most of the barriers to this are still there whether the alcohol is or not.

Now I want to be clear that I am not comparing my situation to an ‘addiction’ or ‘substance use disorder’, or whatever your preferred terminology is.  Neither am I suggesting my life is terribly traumatic or hard.  But that’s precisely the point.  Something we know to be true is quite rarely applied to broader policy issues: we often fail to think of people as a whole person, in a wider social context.  Banal, perhaps, but given my previous post it struck me that it’s still surprisingly worth saying.  Remove the alcohol (or other drug) and, as I’ve written before, that’s all you’ve done.  Too narrow a focus on substance use specifically, and how it is problematic in itself, doesn’t help anyone.

Addition @ 4.45pm:

After an exchange with Aveek Bhattacharya, where we agreed that part of the challenge with going alcohol-free is that pubs - and therefore alcohol - are the default option for socialising and evening activities, I got thinking about specifically why I haven't gone to the pub much.

It's not just that I don't see their appeal when I'm not drunk; I often stay for a drink when I'm driving, and either eke out a small amount of beer or have coke, which I'm not particularly fond of.

And I don't think it can be that the mark-up on soft drinks offends me specifically - it's always cheaper to stay in if you just want to drink.

I think it's something about what I see as the specific appeal of the pub: not just that it's a different atmosphere from drinking at home, but that you're drinking something different.  This might not be the case for everyone - often people might prefer the wine they have at home, or the gin and tonics they make themselves, and I don't know whether Fosters on draft is somehow more exciting than from a can.  (I do, actually - there's plenty of research on the Drug, Set and Setting line that notes that the type of glass and the space you're in affects what you taste.)  But for me, I think the struggle is getting interested in going somewhere to drink Becks Blue when that is precisely what I have available at home, but for a fraction of the price.  I just can't compare bottled beer with cask beer, and most of the pubs I go to feature beers that I can't (or don't) generally buy in bottles anyway.  But maybe I'm a special case.

*I was going to put this quote in the body of the text, but as I was typing it out I wanted to include so much that it’s better here.  It’s from Notes from the Underground:

Man is a frivolous and incongruous creature, and perhaps, like a chess player, loves the process of the game, not the end of it.  And who knows (there is no saying with certainty), perhaps the only goal on earth to which mankind is striving lies in this incessant process of attaining, in other words, in life itself, and not in the thing to be attained, which must always be expressed as a formula, as positive as twice two makes four, and such positiveness is not life, gentlemen, but is the beginning of death.  Anyway, man has always been afraid of this mathematical certainty, and I am afraid of it now.  Granted that man does nothing but seek that mathematical certainty, he traverses oceans, sacrifices his life in the quest, but to succeed, really to find it, dreads, I assure you.  He feel that when he has found it there will be nothing for him to look for.  When workmen have finished their work they do at least receive their pay, they go to the tavern, then they are taken to the police-station – and there is occupation for a week.  But where can man go?  Anyway, one can observe a certain awkwardness about him when he has attained such objects.  He lovesthe process of attaining, but does not quite like to have attained, and that, of course, is very absurd.  In fact, man I s a comical creature; there seems to be a kind of jest in it all … And why are you so firmly, so triumphantly, convinced that only the normal and the positive – in other words, only what is conducive to welfare – is for the advantage of man?  Is not reason in error as regards advantage?  Does not man, perhaps, love something besides well-being?  Perhaps he is just as fond of suffering?  Perhaps suffering is just as great a benefit to him as well-being?  Man is sometimes extraordinarily, passionately, in love with suffering, and that is a fact.

Tuesday 24 October 2017

Are local authority commissioners responsible for rising drug deaths?

I’m not quite as quick on the draw with blog posts as I used to be.  There’s just more things for me to be thinking about at the moment, it seems.  But I wanted to go back to an article from a couple of weeks ago and question some of the assumptions – or maybe more accurately the inferences I think readers were meant to make.

The first thing to note is that I’m sceptical about the validity of claims based on these kinds of FOI responses.  It can be very difficult to compare year on year spending – particularly in the last few years when substance misuse budgets (or at least the representation of them) will have been hugely affected by the movement from NHS to local authorities.

But more substantially, there’s an implication of causality: that these areas are seeing higher drug-related deaths because they’ve made deeper cuts.

I’m not sure that holds, as this wouldn’t just be about the level of cuts, but the way they’ve been implemented.  From my perspective, if a drug treatment service could only do one thing, it would be needle exchange.  If it could do two, I’d add in a simple, low threshold methadone maintenance service.  And that isn’t just my personal preference; that’s because those interventions are the most evidence-based for reducing overdose, crime, and illness or even death from blood borne viruses like HIV and Hepatitis C.

Of course, there’s an argument to be made that you collect evidence about things you’re interested in, and so we have evidence on these things because that‘s what government was interested in the NTA era.  But that’s a side issue.  The main point is that if you were making cuts you could (should?) still maintain the key services that keep people alive.

But that sentence reveals another key assumption: if you were making cuts.  The fact is that all local authorities are making cuts because the funding they receive from central government is being slashed and public health in particular should be worried given the current proposal to fund all their activity (which includes things like sexual health services, health visitors and school nurses*) from local business rates.

And historically it’s the more deprived areas (which are those more likely to have drug deaths because of multiple inequalities) that receive a bigger chunk of their funding from this centrally-allocated pot.  So when these cuts hit, it’s not just that drug treatment is hit; every service is hit harder than in more affluent areas, which are less reliant on central funding to start with, and also more able to top up their funding through business rates and council tax.

What I mean is, the key thing that links areas of high drug related deaths and high levels of budget cuts is simple: deprivation.

To be fair, this is exactly the point that Alex Stevens makes in the article, but I worry that the tone of the article is kicking local councils on one thing where they don’t deserve it, and then letting them off the hook on another.

The tone is that cuts lead to drug related deaths, and maybe they do, but I’m not sure these stats show that and actually I think that in terms of the evidence and the cost of some interventions, it’s easier and cheaper to keep someone alive than it is to get them into ‘recovery’ – partly because we don’t have so much evidence to guide us (if we could agree on what ‘recovery’ is).

That is, the cuts aren’t local government’s fault, and so they shouldn’t be hammered for that; but how they implement the cuts is their decision, and instead Colin Drummond seems to suggest that approaches to treatment were centrally mandated.

Another factor in rising drug mortality, said Colin Drummond, from the Royal College of Psychiatrists, was the coalition government’s decision to treat heroin users with methadone less often and with lower doses, which he described as “political interference in what is essentially a clinical issue”.
He cited examples where “people disengaged from treatment, stopped taking methadone, went back to street drugs and then overdosed”.

I was never convinced by the emphasis the Coalition Government, and Iain Duncan Smith in particular, placed on ‘full’ recovery and the wonders of residential rehab, but my experience was that these statements came from central government at the same time as the NTA lost its teeth and any practical control over local treatment decisions.  That is, central government might have talked about ‘full recovery’, but there was no barrier to local areas maintaining harm reduction services and sticking to Orange Book and NICE guidelines on methadone maintenance and needle exchange so long as there was the will from officers and elected officials within the council.

So kick councils on how they’ve implemented the cuts by all means: have they made methadone maintenance and/or needle exchange less accessible?  Is that evidence-based?  Is it appropriate?  If they’ve maintained it, what has it been at the expense of?

But don’t kick them for making cuts to treatment, or for the perfect storm of the wider cuts and changes to the welfare state that mean overdose and death is more likely.  Think also of housing, benefits, mental health, wider healthcare.  (Not to mention that people are simply ageing, and having to deal with the long-term consequences of a lifetime of smoking.)  Those factors are just as much (or more?) at fault for rising drug-related death rates as the cutting of a group work programme from 5 to 3 days a week.

Of course, you might have read the article with none of those assumptions and reactions.  It just touched a nerve with me as a local authority commissioner.  I’m happy to defend our decisions about how we’ve managed the cuts to our budget, but don’t ask me why we’ve cut the budget, as that’s not my decision.

*Oddly, Izzi Secombe from the Local Government Association seems to have forgotten that the spend on 0-5s healthcare in the Public Health budget dwarfs substance misuse treatment – just look at Figure 2 here: