Saturday 24 November 2018

The iron law of prohibition

I recently wrote about Johann Hari’s book Chasing the Scream.  It’s an unusual thing for me to do to focus so much on another person’s work, and because I enjoyed reading it and felt it had lots of important insights and stories, I felt bad criticising it.  But I’m about to write about it again.

When I was reading the book, I folded down pages or underlined sections that I thought were either interesting or misguided.  Somehow, in my initial post, I missed one key point, which I think is a slightly misleading claim about the potential of legalisation of substances.  I’m going to analyse that, but then argue that nevertheless legalisation may be the right policy.

So, what did I disagree with?  Well, it’s not really Hari’s point; it’s a commonly made claim about how prohibition increases the strength of the drugs.  Hari refers to it as the ‘iron law’ of prohibition.  The point is that if you’re having to smuggle things, then you want the most efficient way of doing it – which in the case of alcohol means spirits rather than beer: a truckload of whisky will satisfy more people than a truckload of beer.  The same could be said of fentanyl today: it’s so potent that it’s much easier to transport than heroin.

This argument is often trotted out by people who want to legalise cannabis, noting that today’s cannabis (often questionably referred to as ‘skunk’) is stronger than what used to be available 20 or more years ago.

And yet whisky wasn’t created by prohibition, and hasn’t become obsolescent in societies where alcohol is legal.  Moreover, people didn’t just drink these things neat; there was a growth in cocktail recipes as people sought to mask the taste.  The transport was separate from the consumption.

And the ‘gin craze’, however accurate as a description of drinking in 18th century Britain, wasn’t driven by prohibition but by availability and affordability.  Hari would also say it was driven by the misery and dislocation of rapid urbanisation.  As I wrote previously, we don’t need to – in fact we shouldn’t – look for a single universal cause of substance use issues.  There isn’t one.

In my original piece, I questioned Hari’s claim that ‘relatively few of us want to get totally shit-faced’ (p.230), given the phenomenon of ‘determined drunkenness’.  Here, I want to stress that associating the level of ‘problem’ with the ‘strength’ of a drug is misguided.  Does whisky lead to more problems than beer?  It’s hard to say.  Certainly not everyone who drinks whisky gets drunk, and it’s perfectly possible to get ‘shit-faced’ drinking only beer – I’m living proof.

And if you’re looking for an efficient way to get ‘shit-faced’, it’s not necessarily the ‘strongest’ drink that you choose, but often the cheapest – like white cider, which is a creation not of prohibition, but our slightly arcane tax system.

A clearer ‘iron law’ of prohibition for me wouldn’t be that it creates the strongest or most dangerous drugs (tobacco and alcohol companies are perfectly competent at that); it’s that the strength and general composition of the drugs is uncertain.

I’m not saying that prohibition doesn’t sometimes increase the strength of drugs, or at least limit our choices, but it’s not an absolute ‘law’ – whereas lack of information (which is a key cause of overdose) is.

Also, strength is not the only determinant of problems.  If we’re talking drunkenness we can’t only blame spirits.  And if we’re talking violence, beer is again often to blame.  And we could probably blame wine for a good number of ‘alcohol-related’ illnesses where there has perhaps been very little violence or drunkenness, but the health harms of alcohol have come home to roost.

And this gets us to something of a choice about prohibition or legalisation.  I don’t want to get into the detail of the debate, partly because a lot of it is supposition, and depends so much on what regime is introduced to regulate substances, what the prior culture of the area is, and so on.  Not all countries that allow alcohol have the same levels of alcohol-related harm – even if they have the same pricing and availability.

As always, I could focus not so much on how legalisation would reduce harm for consumers, but for how it would be game-changing for people involved in the production and distribution of drugs, where violence is endemic and whole states have lost their monopoly on the legitimate use of force.

And looking at the consumer side of things too, taking the example of alcohol, we can suggest that there might be higher rates of drug-related illnesses in the long term for consumers, but there would be less crime and violence.  Alcohol-related crime is generally because people are drunk, but most drugs don’t tend to encourage this – or there’s no reason they should.  The crime on the consumer side for these substances tends to be acquisitive to fund drug use, but this doesn’t happen so much in relation to alcohol (particularly not any more) now alcohol is, in relative terms, so cheap.

As others have outlined, in order to ensure there is no black market, the legal price for drugs needs to be relatively low, and of course a potential consequence of that is use increasing, along with associated harm.  That’s what we can see with the growth in alcohol consumption in the UK from the 1960s to 2004.  Various factors combined to make alcohol consumption increase as it became more acceptable, more affordable, and more available.

So is the price worth paying?  Well, for me, as I’ve said, the benefits for producer countries and those involved in the drug trade are clear.  But for consumers and those around them it’s potentially more of a mixed bag.  But I’m still prepared to say it’s worth it – just not because of the ‘iron law’.

Again, without going into the detail (other people can do that better than me), I see this as a question of whether we would prefer the situation today where for consumers and producers life is (to quote another political theorist) nasty, brutish and short, to the situation under legalisation where we’d probably see some higher rates of chronic conditions such as cancer (which we’ve seen with increased alcohol use).  I’d prefer the latter.

That life is nasty, brutish and short for some people isn’t the result of particular substances, even when they’ve been strengthened and adulterated by prohibition.  The nastiness is the result of the wider structures, which can be changed.

Friday 23 November 2018

In praise of fellowship

Last night I went to my first ever Alcoholics Anonymous (AA) meeting.  It was an open meeting, specially put on for Alcohol Awareness Week.  I’ve been meaning to go to an open meeting for years, and there are opportunities every month, but (like so many things) it’s only getting a date in the diary that made me do it.  I was encouraged that a number of other professionals were there too, representing local support and care organisations from midwifery to probation.

I found the meeting genuinely moving – but of course I would.  Who wouldn’t, hearing stories being shared not only from two regular meeting attendees, but also someone who attends Al-Anon – the sister organisation of AA that supports people whose loved ones have issues with alcohol.  The moving thing wasn’t simply those testimonies, but something about bringing home the human side of my job.  I don’t mean this in the way we often do: slightly patronising, remembering there are ‘service users’ not just numbers in spreadsheets.  I mean something about real human connection.  One person who is alive speaking to another.  I know this sounds both cryptic and trite, so I’ve tried to write something here that explains what I mean.

Sitting in the room, I felt like I was somehow back in the past.

Writing that on its own makes me feel like I’m perpetuating a stereotype of AA, of people sitting in a cold, damp church hall, wearing unfashionable clothes, drinking flavourless coffee.  My experience was far from that.  The coffee was decent, the room was warm, modern and comfortable – and I’m certainly in no position to comment on anyone’s dress sense.

What I mean is that the kindness, community and somehow ordinariness reminded me of the stability and community of my childhood.  I felt like a weight had been lifted.

I tried to explain this afterwards to someone else there, but failed.  I said that sitting there, listening to people’s stories, made me think (as I have about social work in the past) that, done well, this kind of fellowship and community and the genuinely mutual aid it offers would be of benefit to most people.

Of course, the person I was speaking to reasonably and carefully explained two things.  First, that these groups were open to and designed for people who had issues with alcohol.  Second, that these ‘issues’ were of a particular kind – as a doctor quoted in the ‘Big Book’ that I picked up there stated: ‘the action of alcohol on these chronic alcoholics is a manifestation of an allergy; that the phenomenon of craving is limited to this class … These allergic types can never safely use alcohol in any format at all’ (p.xxviii).

I hope I’ve always been respectful to this point of view.  To praise the general principle of mutual aid isn’t to deny the special nature of ‘alcoholism’.

But here’s where I may have been slightly less respectful.  I get caught up in intellectual games and the pleasure of having a neat (ideally slightly unexpected) position when I write about alcohol and other drugs – though I nearly always end up sitting on the fence somehow.

The intellectual game that fascinates me is the classic discussion of structure versus agency, as sociologists would put it.  Or in terms of alcohol problems, does the issue lie in the person or in the bottle – and I like to say that things are complex, nuanced, shades of grey.  (In work, by contrast, I generally tend to want to know ‘the answer’ and get on to ‘do something’.)  This interest in nuance (or fence-sitting) has led me in the past to question whether ‘addiction’ really exists, and to emphasise that if ‘alcoholics’ exist then they are a small sub-section of the group of people who have problems with alcohol, and if we get too caught up in defining ‘addiction’ we’ll fail to pay attention to the whole range of people who are struggling.

So I’ve not really had too much time for this concept of a particular ‘class’ of ‘alcoholics’, as the quote in the ‘Big Book’ puts it.  (Though re-reading some of my old pieces this morning, maybe my love of ‘nuance’ has meant I’m more reasonable than I think.)  There are certainly those who see the use of terminology like ‘alcoholic’ as not only stigmatising but limiting people’s autonomy and potential for recovery.

Having now been to a meeting, though, I feel I’ve been a bit too cold and detached in my assessment.  It’s the same way I feel, on reflection, about the things I’ve written saying that the 2016 Psychoactive Substances Act could, in the long term, be helpful for UK drug policy debates.  The problem with intellectual games, abstract principles and ‘long term’ policy debates is that they’re not human, they don’t feel.  (In the long run, we are all dead.)

The most revealing moment in the meeting was, for me, when various people spoke about ideas of ‘God’ and a ‘higher power’.  This is one of the most debated features of AA, and the one many sceptics leap upon to discredit or disengage with it.

One person explained that, sitting in a church, he wouldn’t feel like he was surrounded by people who understood him, whereas in AA he knew ‘these were my people’.  This is a bit like a phrase I remember Mark Gilman using a few years ago when he came to speak in Dorset, describing an ‘alcoholic’ as someone who has ‘got the spots’ – but it’s also something more.  It’s not just sitting in a room with people who have the same condition or ‘illness’ (many of us have done that at one time or another, and it’s not always useful or fulfilling); it’s about the sense of fellowship.  As someone else explained, for her the ‘higher power’ was something outside of, beyond, herself: the other people in the room.  This is the human, feeling element that I am somehow too easily able to switch off when analysing or writing.

The term ‘alcoholic’ is used in this context without shame or judgement.  It’s seen as a description of a ‘class’ of people, and this ‘class’ isn’t simply defined by alcohol consumed.  It’s a class for whom, as one person put it to me afterwards, just stopping drinking isn’t the solution – in fact, without some wider support, that can often make things worse.

Of course, such people are not the only people who suffer harm from alcohol.  And we need to be flexible in our idea of ‘rock bottom’ (and whether someone actually has to hit it to find recovery).  But it’s hard to sit in that room and feel anything but warmth and admiration for what this fellowship – these people – have done and continue to do.

So going to the meeting helped me remember another way of being in the world.  Somehow more relaxed, more grateful, more structured.  There are various reasons I feel I’ve lost that recently.

But it also made me consider my own drinking.  I’ve not got very far in reading the ‘Big Book’, and so I keep coming back to that section at the beginning by a doctor – William D Silkworth.  There’s a revealing sentence that opens a paragraph describing the nature of ‘the alcoholic’: ‘Men and women drink essentially because they like the effect produced by alcohol’ (p.xxviii).  I certainly do.  I drafted this post last night, and was already envisaging the train back from London on Friday night where I’d enjoy a couple of cans of ‘train beer’.

I’m not suggesting my drinking is ‘alcoholic’, but two things in the past week have made me question my relationship with alcohol.

One was meeting staff and PhD students when I went back to Bournemouth University last Friday to teach a session on ‘controversial cultures’.  Discussing ‘binge’ drinking culture as potentially controversial, I was asked if there was something in the British psyche that means we can’t drink sensibly.  Thinking of James Nicholls, I argued that there isn’t a single, fixed British drinking culture and, anticipating this week’s Alcohol Awareness theme, I emphasised that ‘change’ is possible at a population as well as an individual level.

And the second moment was last night at the AA meeting.  The description of how drinking, for some people, was a way of avoiding the discomfort of living, the anxiety of navigating the world, the awkwardness of being oneself.  (These are all poor phrases to represent what people actually described.  I can’t represent their eloquence in my writing.)

This is why I drink too.  It takes the edge off.

And this, generally, is why people use any drug.  As I remember Wulf Livingston arguing persuasively at NDSAG, much drug use can be seen as functional in some way, even when it’s part of what would generally be labelled ‘misuse’: if the drugs weren’t serving some purpose, people wouldn’t use them.  Perhaps in the long term there’s a better solution, but drugs, too, are a solution of sorts.

Most of us just don’t reach the point described by several people at the meeting, where they were so tired of the repeated pattern of using/drinking that they no longer wanted that life (and therefore no longer wanted a drink because they knew how that ended).  For those of us still drinking, we’ve decided at some level that the benefits still outweigh the costs.

And I don’t just mean a small glass of wine over dinner.  I haven’t tried many drugs, but for the moment I can certainly say that alcohol is ‘my’ drug.  I respect that this isn’t true for everyone (or even most people), but fundamentally I struggle to genuinely understand why people wouldn’t like the feeling of drunkenness.  Why, if there were no commitments tomorrow, wouldn’t people always say yes to another drink?

But sitting in that room, I wondered about that.  Is it a healthy, happy approach to life: when I can, I try not to be fully conscious or present?

Just like my writing, I wonder if my drinking is an attempt to show off, to be special.  Am I trying to be one of Steve Earnshaw’s intellectual, ‘existential alcoholics’?  (Just without the courage of their convictions to be truly destructive.)

And that brings me back to that starting point, which could be seen as simultaneously undermining and celebrating the principles and practices of AA.

(Wait for it, but just so you’re warned, this is the supposedly clever conclusion bit I always aim for when writing a piece like this.  In this case part of me is thinking that it’s particularly clever because I’m being self-referential and self-critical given that I’ve recently been questioning Johann Hari’s claim that the opposite of addiction is connection, and yet here I am praising connection as a solution to addiction.)

The value of AA, to me, is this reminder of the ‘miracle’ of an ‘ordinary’ life, and the benefits of ‘fellowship’.  These are amazingly special things, affirming the value of AA – and yet they are also surely universal (as much as anything can be), which leads me to question how ‘special’ this approach really is.

But although we could all perhaps learn from AA, and despite the fact that this ‘class’ of ‘alcoholics’ aren’t solely defined by their drinking habits, there remains something unique: fortunately most of us are never placed in situations so extreme that we have to think in this way.  And this is perhaps where all of us can take a moment to express what was so fundamental for so many people in the room last night: gratitude.

Tuesday 20 November 2018

The disease of black and white thinking about addiction

Today (#OurDay) I was at an event in Bournemouth where we were discussing how we could get the different services to work efficiently and effectively together, when there’s decreasing resources at the same time as many of the people who need support are facing increasing challenges, such as unstable housing, complicating health conditions, unemployment, benefits cuts and so on.  As one person described it, it’s a ‘perfect storm’.

This isn’t news, and although the suggestions made by staff were excellent, I want to focus on some conversations I had outside the main discussions – over lunch.

The first thing to note is that despite the astonishing passion and dedication of these staff, who are quite simply not paid enough, the environment they are working in is taking its toll: those decreasing funds and increasing challenges mean people are struggling to see that they’re genuinely making a difference.  Is it just pushing water uphill?  At one point do you decide to stop propping up a system you don’t believe in?

And that brings me onto a bigger point about beliefs that I want to focus on here.

I was surprised that there was still considerable passion not just in the delivery of treatment, but in the recovery / harm reduction debate.  I had naively thought we’d buried the hatchet, but it’s very much alive in terms of how people see the decisions that different organisations and clinicians make.  In a sense, that’s not surprising, though, and it’s partly the fault of commissioners (and politicians) for doing one of two things.

First (and this is my own typical failing) we’ve sometimes been guilty of ducking the issue, of imagining that just saying things like ‘evidence based’ or ‘Orange Book’ will dissolve any conflict.  It won’t.  We should be savvy enough to know that there’s plenty of wiggle room in NICE and PHE guidelines, and there’s always that black box of ‘clinical judgement’.

Second, and conversely, we’ve sometimes been too definite.  Sometimes issues have been presented as ‘black and white’, with a proposal being ‘right’ and all other options ‘wrong’.  No wonder, then, that as the goalposts seem to be moved staff feel betrayed or lied to: if the previous policy was ‘right’, surely this one is ‘wrong – or vice versa.

We should all be a little more cautious when ‘selling’ policies, and open and honest about our motivations and the limits of our knowledge.  (We should also obviously be careful not to introduce any genuinely ‘wrong’ policies in the first place.)

The problem is that when someone is presenting something as a black and white issue, and you’re not sure you agree with their position, it’s easy to get caught in that same binary way of thinking – when what I’d prefer with most of this is to suggest that there isn’t a single right approach, and if we want to talk about services that are tailored to the client, we need to genuinely listen to them.  A one-size fits all approach, whether from a self-proclaimed ‘recovery’ or ‘harm reduction’ perspective is likely to be unhelpful for a number of people.

If this all sounds a bit cryptic, that’s fine.  My real point is something almost trivial about the theory of addiction.  (Which of course is never cryptic.)

In my experience of discussions about ‘addiction’, certain high-minded academics critique the ‘disease model’ of addiction, and possibly even the whole concept.  Then they are advised that the disease model, as championed by NIDA, is valuable because it helps stop addiction being stigmatised.  If people are ‘ill’ rather than ‘bad’, then surely there’s no reason to marginalise them and not offer reasonable healthcare and support?

It always feels to me that critiques of the disease model are therefore labelled as abstract, idealistic, and not in touch with ‘real’ politics or treatment.  This is brought home even more by the close links between the disease model and the ideas of fellowships like Alcoholics Anonymous.

Of course this is naïve on two counts.

First, academics can also have lived experience.  Marc Lewis, who co-wrote one of the pieces linked to above, makes no secret of his.  Indeed, it’s his experience that led him to a different perspective on the issue.  And more broadly, these aren’t simply abstract, academic debates; they can shape policy and treatment.

Second, the idea that being ‘ill’ isn’t stigmatising is absurd.  Any number of diseases and illnesses have been considered moral failings, or simply dangerous and therefore stigmatising, from leprosy to cerebral palsy, to HIV to name just a few.  We don’t manage to treat everyone who is ill with dignity.

Is the disease contagious?  Is it somehow caused by someone’s ‘lifestyle’ (or that of their parents)?  These are key questions not just for the stigma surrounding addiction, but many other illnesses.  And they’re not easy to answer.  (If recovery is contagious, then isn’t addiction?)

But it seems to me that this remains the frame of the debate: brain disease a realistic, pragmatic, stigma-reducing idea; critiques perhaps well-intentioned, but abstract and academic.  Criticising the disease model is seen as a hobby of abstract academic thinkers not grounded in the real world.  (Maybe that’s me being oversensitive, but stick with me.)

That’s why I was surprised to hear critics of ‘harm reduction’ (self-confessed advocates of ‘recovery’) also criticising the disease model.  But of course this made perfect sense.  For them, the reliance on methadone (and an emphasis on ‘optimal dose’ in the Orange Book that is relatively high compared to much practice) represented a medicalising of addiction based on a disease model.  If you diagnose a disease, our standard medical approach is to prescribe, well, a medicine – in this case methadone.  But methadone is nothing like an antibiotic, or steroid.  It doesn’t in itself fight an infection or reduce swelling; it feeds a physiological dependency.

I don’t really want to get drawn into the details of this debate.  It would take too long and the evidence isn’t always perfectly clear.  It would also mean conducting a debate in ‘bright lines’ when the reality is a little more muddy.

I just want to pause on this point: recovery advocates can also be critics of the disease model.  This is of course completely coherent, and maybe it’s only me who’s intrigued, but it highlights that these debates aren’t simply black and white.  If we had to choose a ‘side’ between ‘harm reduction’ or ‘recovery’ we might find ourselves alongside with some people we don’t agree with regarding the very nature of ‘addiction’.

An overly prescriptive idea of ‘right’ and ‘wrong’ approaches to treatment actually contains the seeds of its own downfall.  If your enemy’s enemy is your friend, you’ll find that, actually, we’re all friends.  We shouldn’t be choosing sides.  Not when there’s bigger battles to fight – like that perfect storm.

Monday 19 November 2018

Alcohol Change: The Voice of Moderation?

Today the new charity formed out of the merger of Alcohol Concern and Alcohol Research UK has been launched.  You might remember that when this merger was first announced I was pretty sceptical that it could work.

I felt that fundamentally the two organisations had different visions that were basically at odds with each other.  Alcohol Research UK sought to improve knowledge and information to help reduce alcohol-related harm, while Alcohol Concern sought to eliminate alcohol-related harm altogether.

These might only be seen as matters of degree, but the idea of a world free from alcohol harm is as utopian as the UN’s claim that we should create a ‘drug free world’.  Given what we know about alcohol, the only way to guarantee you won’t suffer any harm related to it is not only for you not to drink, but for no-one around you to drink.  A world free from alcohol harm means, in reality, a world free from alcohol.

The new organisation – Alcohol Change – defines its vision as being a society where there is an end to ‘serious alcohol harm’, and envisages bringing this about by improving knowledge, policy and treatment, and therefore changing cultural norms and drinking behaviours.

You can read about Alcohol Change’s proposed approach in a kind of ‘state of the nation’ report released to coincide with Alcohol Awareness Week.  I just want to pick out a few gems and talking points from this that have made me eat humble pie: I think that maybe the staff and Trustees at Alcohol Change have managed to do what I thought was if not impossible then certainly highly challenging.

First, there’s a paragraph in Alan Maryon-Davis’ introduction that I think should be shared with every journalist and political commentator ever considering discussing alcohol policy:
There is nothing inevitable about the way we drink, how we behave when drinking or how difficult it is to access the support that can help turn lives around. Research shows that the majority of dependent drinkers recover, that heavy drinkers can make new choices, and that the social and cultural environment in which people drink can and does change. Change is possible for individuals, and it is possible for society. (p.1)
Far too often we view drinking habits as unchanging and unchangeable: we’ve been drinking too much as a nation since well before William the Conqueror arrived.
‘Drinking in particular was a universal practice in which occupation they passed entire nights as well as days. They consumed their whole sustenance in mean and despicable houses, unlike the Normans and French, who in noble and splendid mansions lived in frugality … They were accustomed to eat till they became surfeited and to drink till they were sick. The latter qualities they imparted to their conquerors.’ William of Malmesbury, 12th century

But that raises the inevitable question: if change happens, and we can shape it, what sort of culture should we be aiming for?  And this is where the ideas of knowledge, information and choice come through strongly and, for me, positively in the Alcohol Change document.

I’m generally sceptical about health and behaviour change programmes based around ‘choice’ because they tend to ignore (or at least downplay) the level to which people’s choices are structured by the situation they find themselves in: who their parents are; where they live; how much money they have; the job they have; the personal relationships surrounding them; and so on.

But this document doesn’t duck this issue; it notes the importance of culture and norms in shaping our preferences and expectations, and how these in turn can be shaped by policy levers.

The changes in alcohol consumption shown in the graph above were partly down to some short and medium terms factors – both conscious policy decisions and the simple fact of a dire economic situation – but they cast a very long shadow, with alcohol consumption for most the twentieth century remaining at historically low levels.

And the policy point is made with a bit of nuance too.  As I’ve argued elsewhere, too often policy discussions focus on exciting new initiatives – such as minimum unit pricing – at the national or even international level.  In reality, there’s massive variety and impact generated by local decision-making – but somehow Town Halls are seen as less interesting than Whitehall.  It’s refreshing, therefore, to read a strategic document that emphasises the importance of engaging with ‘local government … commissioners of treatment services [that’s me!], the police, local planning, and all the other local stakeholders with a role in reducing alcohol harms’ (p.11).

For me, this document seems to have got the approach just right.

There will of course be campaigners who feel that ‘serious’ is a weasel word that dilutes the utopian aspiration of a world completely free from alcohol harm, and the focus on knowledge and information is a naïve concession to the evil industry of ‘big alcohol’.  And conversely there will be libertarians who see the emphasis on culture change as beyond the scope of reasonable activities, which should allow people to pursue their own choices.

For me, that’s the ideal position for a new charity like this to be in.  I’ve complained before about the polarised, adversarial approach that often characterises alcohol policy debates – ‘public health’ versus ‘the industry’ – where both sides have some valid points but neither is listening to the other.

There will always be these voices at either end of the spectrum, and there’s little value in duplicating one or the other – a simple approach to balance will mean both are heard (or at least given the opportunity to shout over each other).

The value of Alcohol Change should rest in being a different voice, not associated with a partisan position but as a trusted messenger and ‘truth teller’.  And in playing that role – rather than simply being a vocal, idealistic (even utopian) campaigning organisation – it may find its ideas and proposals are listened to more seriously than either of the two extremes.  As so many alcohol researchers and lobbyists have noted, there is great power in being able to define what the ‘moderation’ is.  Alcohol Change can position itself as the voice of moderation in more ways than one.

The last time I wrote about this merger, I summed up my scepticism with a reflection on my personal feelings – valuable because so often (as drinkers, professionals or campaigners) our views on alcohol are shaped by personal experiences and beliefs.  I said that while I would be keen to work for Alcohol Research UK, I just couldn’t see myself being a good fit with Alcohol Concern, given its hardline, lobbying approach.  I don’t know whether it’s praise or not, but I can honestly say that Alcohol Change looks like the sort of organisation I’d enjoy working for.

Monday 29 October 2018

Are compassion and connection the answer to drug policy debates?

Two people I have a huge amount of respect for – Suzi Gage and Harry Sumnall – have just published a paper encouraging us all to have a bit more restraint when discussing the implications of the Rat Park experiment.  Just like the original author, Bruce Alexander, did, in actual fact.

I was familiar with the experiment somewhere back in the mists of time, but (setting aside Bruce Alexander’s appearance at the 2016 New Directions in the Study of Alcohol conference) the reason it’s on my radar now is that Johann Hari and others have used it to campaign for the legalisation and regulation of drugs.

For those of you who are interested in finding out more about the experiment, I’d recommend Suzi and Harry’s article.  Basically, the study is typically seen as showing that a rat’s propensity to get ‘addicted’ to a drug (morphine in the case of Bruce Alexander’s work, but others have used cocaine) is not simply dependent on the drug, but their environment.  Put rats in bare, individual cages and they’ll use intoxicating drugs to the point of incapacitation or even death; put them together in a ‘Rat Park’ with other rats and entertainment and they’ll pretty much ignore the drugs.

The problem is, of course, that it’s more complicated than that, and in any case it’s hard to extrapolate from a small animal study to a global policy for humans.  It’s often overplayed because it’s an eye-catching story.  In itself, the research isn’t miles from the general consensus about what causes issues like addiction: a mixture of the substance, the person and wider circumstances.  The ‘biopsychosocial’ model, if you like.

The point of all this discussion is that reading the article reminded me I had recently made the effort to read Johann Hari’s Chasing the Scream in full.  I felt guilty at criticising him on the basis of TED talks or newspaper articles without actually having read the whole book.

I’m not particularly negative about the book.  It’s well written and the interviews and storytelling are engaging.  I also want to believe the conclusions, and I like the way he writes about how he reached them, and the uncertainty about whether they hang together.  I largely agree with the conclusions.  I think the world would be a safer place if more drugs were regulated and available through legal routes, whether prescribed or sold.

Unfortunately, Hari was right to be concerned: the conclusions don’t actually hang together.  I know the book isn’t new, and other people have analysed it before me, but I it’s been a useful exercise for me to think all this through, and it’s important for our debates about drug policy.  It can feel like we’re at a fork in the road at the moment, not just seeing possibilities for change, but real change itself.  Cannabis is legal for recreational use in countries around the world, and more and more places are operating decriminalisation, either in theory or practice.  The arguments and claims we make for these policies, are important.

So just noting a few of the issues with Johann Hari’s claims, he can’t seem to decide whether drug use is exciting or boring – and he sees this as crucial to the solution.  So he quotes John Marks, who prescribed injectable heroin on the Wirral in the 1980s, as saying: ‘I try to make my clients realise that what they’re doing is boring, boring, boring.’  Except that’s not (always) the case.  And it’s not what Hari says elsewhere in the book.  Using heroin can be exciting – and not just in terms of the chemical ‘high’.  As Steve Wakeman has powerfully described, the routine of getting together enough money, making the deal and using the drugs provides a focus and some excitement to the day, and also offers people a sense of expertise and achievement.  It can also provide a community.

As I say, Johann Hari knows this.  When he quotes John Marks on p.211, he has already quoted Bruce Alexander on p.176 saying that when the life of a heroin user is compared with what might happen if they got a ‘McJob’ or became a janitor, it seems ‘really exciting’.  Hari doesn’t have to agree with everyone he quotes, but he does need to balance different perspectives up against each other.

Of course it’s possible that, following the idea that people ‘grow out’ of most patterns of substance use, heroin use is exciting to start with, and maybe for many years, but at a certain point there comes a time when it seems ‘boring, boring, boring’.  But as the Bruce Alexander point shows, this depends on what else is on offer.  It also means that one approach won’t make sense for everyone.

This has important consequences for policy.  Heroin assisted treatment (HAT) is more likely to work if the alternative isn’t seen as exciting – because HAT will never be exciting in that way, as Steve Wakeman has again described so well.

So we’re not clear from this book what treatment we should be offering people, but perhaps that isn’t much of a criticism.  This is really a book about the global ‘war on drugs’.  So let’s think about drug policy more broadly.  Hari suggests that use of substances isn’t down to access, but in fact there’s plenty of evidence that use of alcohol (and in fact other drugs) goes up and down depending on how accessible it is.  Some might argue that overall levels of substance use stay the same, people just switch from one substance to another (even across legal boundaries).  However, we know that overall substance use varies over time, and this is partly about access and affordability.  In many countries, the interwar years saw slumps in alcohol use not because everyone was switching to other drugs, but because money was tight and it was harder to get hold of a drink because of stricter controls or even prohibition.

But citing Bruce Alexander again, Hari states: ‘The answer doesn’t lie in access.  It lies in agony.  Outbreaks of addiction have always taken place … when there was a sudden rise in isolation and distress – from the gin-soaked slums of London in the eighteenth century to the terrified troops in Vietnam’ (p.228).

There are two problems with this approach.

First, it’s not clear that high levels of substance use are associated with agony so much as affluence.  Perhaps affluence comes at times of change and upheaval, but the relationship is more complicated than that.  Of course, ‘addiction’ is a problematic concept, and it might be that if we define it tightly enough then we can see that instances increase at times of ‘agony’.  There’s certainly no doubt that difficult experiences can drive people to substance use.  But dealing only with ‘agony’ – or even seeking the prevention of ‘agony’ would leave us with a pretty narrow, ineffective drugs policy.  Too often, the book slides into describing drug use as inherently problematic (e.g. pp.241-2) – and then moments later talking about the inevitable human desire for intoxication.

Second, availability is a key factor that is part of the mix.  The ‘gin crisis’ (or rather the perception of a crisis) occurs not simply because of an increase in agony, but also because of availability of a particular product, which has been developed through technological innovations and the confluence of foreign policy (gin as a patriotic Protestant alternative to French brandy).  Use of heroin amongst American troops in Vietnam was partly the result of it being available.  Why not other substances?

The response to this is that the substance is secondary: whatever is affordable and available will be used to soothe the pain.  But was there less pain in the ‘dark ages’?  During the English Civil War?  During the World Wars of the twentieth century?  We’re drinking more now.  If drinking follows pain, that simply wouldn’t be true.

And, crucially, we do drink despite it being legal.  Campaigners might see legalisation as ‘a drama reduction programme’ (p.263), but the most important bit of drama relates to the murderous crime drama that is the production and distribution of drugs.  There’s plenty of drama in consumption even when substances are legal.  If the ‘fun’ were taken out of drug use, wouldn’t people move onto something else (like the ‘carnival of crime’) to get it?

These might seem like flippant points, but they have important implications for policy.  ‘Addiction’ is not the only problem related to substance use, and it doesn’t only relate to ‘agony’, though this can be an important factor.

To challenge this ‘agony’, Hari’s rallying cry is that the opposite of addiction isn’t sobriety, but ‘connection’ (p.293).  ‘A compassionate approach leads to less addiction’ (p.252).  His hope is that people and politicians of all stripes will begin to see that drug policy ‘isn’t a debate about values’ but rather a debate about harm.  ‘We all want to protect children from drugs’ (p.252), for example; we just disagree about how best to do this.  I’ve written before about how ‘harm’ is extremely hard to define.  In fact, it’s a weasel word that makes us think we agree when we don’t.

I don’t want to downplay the importance of Hari’s claims with these criticisms.  When he describes the issues surrounding the criminalisation of drugs and the broader social and economic deprivation that often goes with them (p.238), we could be talking about many areas of the UK today: if we take away the drugs, what is a person potentially left with?  No job, or realistic prospect of getting one.  No stable, safe, warm and dry accommodation.  No supportive personal relationships.  Of course this is a particularly negative view, and everyone carries assets with (and within) them, but the reality is that ‘recovery capital’, just like all other forms of capital, is not evenly distributed across society.

But the general point regarding legalisation is that it would reduce stigma.  Hari quotes Joao Figueira who suggests that people who’ve got into problems with alcohol were always treated as ‘friends’ and given support, and now the same humanity and sympathy are offered to people who use illicit drugs (p.250).  But I don’t recognise that in our approach to people in the UK today.  Public debate, and even plenty of private interactions, often don’t show humanity and compassion to people who run into issues with any substance, including alcohol.  (If you doubt my position, take a look at the articles and comments on the Dorset Echo website from time to time.)

Legalisation is not an easy answer to reducing stigma.  In fact, as substances become more available, and more people use them without problems, the potential judgement might become more harsh.  At the moment, many people have misconceptions that illegal drugs are immediately addictive.  If they were disabused of this notion by seeing plenty of people using them recreationally, perhaps they would identify the problem as residing not in the substance but the individual.

I agree that compassion could reduce problems surrounding drugs, or at least help us deal more effectively with them.  The issue is that compassion, and the approach Hari sees as compassionate, need some serious work to make them politically acceptable.

Understandably, Hari seems to be writing for the people who are going to read his book: bluntly, middle-class, liberal, intellectuals.  When he claims that we all want to reduce harm, I don’t recognise that in our political culture today.  There are plenty of people who see punishment not as a form of rehabilitation that may be more or less effective, but as something that has a moral purpose of its own.  When Hari suggests that ‘most of us don’t object to drug use in and of itself.  We worry about the harms caused by drug use’ (p.266), I think he underestimates the public opinion challenge surrounding legalisation.  Even drinking to intoxication is condemned in our society, and that’s making use of a legal drug.  Use of illicit intoxicants is far from acceptable.

I know this is changing, and there are organisations like VolteFace who are making waves in changing the terms of debate, but this is hard work that needs to be done carefully, and it can’t be done simply by calling for compassion or believing that intoxication is acceptable.

Reading the book reminded me of why I find this kind of line on drugs policy disappointing: it’s looking for a magic solution to a multifaceted issue (or, more accurately, a whole range of issues) and overplaying its hand.  That’s why the article by Suzi and Harry reminded me of my thoughts on the book, which I’ve meaning to write down for a while: we need to be really careful about what we’re promising, and the problems we’re trying to solve, otherwise we could end up in a worse position than we’re starting from.

Tuesday 11 September 2018

Let's have an end to tall tales about addiction

I’ve talked about addiction on this blog before.  I’m not being flippant, given basically the whole thing is about alcohol and other drugs.  I mean I’ve written about the nature of addiction, and whether it’s useful as a term.

I think I’ve always been honest that I’m not an expert on this.  I’m not a clinician or a technical researcher.  I’m a council worker who’s done a bit of academic work – in sociology!  I’m not entirely sure why, but I’ve started thinking about this again.  Well, I know why – I’ve been passed some fascinating reading – but I’m not sure what started this or why I’ve found it particularly engaging.

Anyway, onto the meat of the thing.  I’ve written before about how we’re generally attracted to black and white, binary thinking.  In addiction debates, this often plays out as a choice as to whether ‘the problem’ lies in the person or the substance.  For example, is it that certain people are unable to drink alcohol in a controlled fashion (‘I am an alcoholic’ – but other people aren’t) or that there is something inherently problematic about the substance itself (we should control or even ban alcohol because it is ‘no ordinary commodity’)?

Of course I’m bound to say, being the person I am, that ‘it’s a bit of both’, but often that nuance means sacrificing clarity, and the action that tends to go along with it.  As academics (and in fact civil servants) are told so often: it’s hard to prompt the implementation of an initiative if you don’t have a clear ‘narrative’ to explain it.  I’m not sure we have a clear narrative on substances and addiction.  Or maybe we do, but it’s not stable: it’s clear for a few years, then it changes.

Because then along came Johann Hari, re-popularising Bruce Alexander’s Rat Park, explaining that the key to understanding addiction is social connection: if you put rats not in bare cages, but an open ‘park’ with company and plenty of fun activities, they don’t want to use morphine/cocaine.

So we have a third explanation: addiction is about social context.

That’s not a new insight; Rat Park isn’t a new experiment.  But what is new (to me, though still predating Johann Hari’s interest) is an article by Gene Heyman (shared with me by Gary Wallace, a wonderful commissioner doing wonderful things in Plymouth).  Heyman looks at big datasets from the USA to assess hypotheses like whether addiction is related to the substance, the individual, their social context (e.g. education) etc.

It felt particularly timely reading this as issues around decriminalisation, regulation etc seem to be more on the political agenda than they have been for years, and the sector (in the UK) is increasingly operating under a new organising framework: no longer crime or employment, but ‘adverse childhood experiences’.  That is, substance use is often a response to trauma.

I have a lot of time for this explanation (for a more academic exploration, see Hanna Pickard’s work).  However, not every heroin user is a victim of abuse, or a survivor or trauma, and this must be more widespread than we care to admit if we were to include all dependent drinkers in this category.

Of course, that raises two questions: first, is dependence the same as a ‘substance use disorder’ or ‘addiction’; and second, what does this mean for the claim that addiction is an ‘equal opportunities’ disorder?

I would respond by saying that this is political, and Gene Hyeman can help us with this.  It’s political because the choice of what narrative or ‘story’ to tell about addiction affects the policy solutions we come up with (and how likely these are to be implemented).  (Think Kettil Bruun choosing to emphasise the population-level issues associated with alcohol, partly in order to avoid stigmatising ‘alcoholics’.)  Gene Heyman helps because his way of conceptualising the issue cuts through some of this.

Heyman notes that we have a definition issue: what is addiction, and how does it relate to dependency?  He notes that discussions often become circular: if you don’t behave in a certain way (including relapsing or needing treatment) then you weren’t ‘really addicted’ in the first place.

But he points out that so long as we’re reasonably consistent in how we apply it, DSM (IV) definitions are pretty reliable.  These count symptoms, and if you have enough then you count as having a substance use disorder (dependent on terminology at the time).  (I’m going to ask properly knowledgeable professionals to cut me some slack here.  I’m no expert, as I’ve said, but I’m also trying to make this simple and straightforward.)

We need to be careful whether we’re seeing recovery as meaning you’ve still got ‘symptoms’, but below the threshold number, or in fact you’re now not using at all (you’ve got no symptoms).  But there are ways of controlling for this, and basically, once we get beyond this, we can see something of a standard distribution of misuse, just with varying levels of duration.  (You’ll need to read the whole article if you want a proper, reasoned explanation of this conclusion.)

And we need to remember that the people we see in treatment are a small section of those who use substances, and even of those who run into issues with substances.  I’m perfectly happy with that.  In treatment discourses, we often talk about ‘recovery capital’, meaning the stock of factors that support people to improve their situation.

Generally, people have a much better chance of recovery: if they have some kind of financial safety net and stable accommodation (physical capital); if their wider health is pretty good and they have some life and employment skills they can draw on (human capital); if they have a particular set of values that fit with the life they’re trying to form (cultural capital); and if they’re surrounded by supportive, like-minded people (social capital).

For lots of people who drink too much, they have a good stock of this recovery capital, and if they can break the habit of drinking heavily then they will quickly improve their health and wider social situation.  For these people, for example, a GP-led detox might be perfectly sufficient for them to maintain their recovery for a long time.

Or think of the memoirs and blogs that seem to have multiplied in recent years, describing how once the author jettisons alcohol they become fitter, happier and more productive.  I know that’s a simplification of the narratives, but it can sometimes feel that there’s assumption that the other elements of someone’s life are ready to fall into place if someone stops drinking, even if this takes some work.

I think it’s important to remember that’s not so easy if there’s no stable accommodation that’s accessible to you, if your personal relationships are destructive, with little chance of escape, there’s no jobs locally and your employment prospects aren’t great because your education and CV don’t look too great to people who are looking at you for the first time.

It’s people facing these more challenging circumstances – with less ‘recovery capital’ – who are most likely (or should be most likely) to benefit from treatment services.  They’re also – for precisely that reason – the people most likely to relapse, and to struggle to recover long term.

I know I’m telling people what they already know.  I know this could be seen as a straw man.  (Even Peter Hitchens, a vocal opponent of intoxication and substance use generally, can’t decide if it’s the substances that are evil, or the people using them who are flawed – he probably thinks it’s a bit of both!)

But first I would recommend that anyone who hasn’t reads through the article.  It has interesting points to make about inequalities, prohibition, and what treatment can and should offer.

Second, I want to ask (or just wonder aloud) whether it’s possible to break away from the soundbite approach of ‘addiction is about social connection’ or ‘addiction is a response to trauma’ or ‘addiction is based on genetic predispositions’ or ‘addiction is the result of using an addictive substance’.  It’s all and none of these things, for a whole number of people.  How can we talk about ‘tailored treatment’ and ‘trauma-informed care’ if we can’t even see the nuances in the disorder we’re trying to treat?

I know the attraction of a big idea.  I know the attraction of a simple ‘story’.  But attractive as that is, it often leads to the wrong solutions, and all interpretations are time-limited: with falling crime rates, we don’t talk so much about heroin users committing acquisitive crime now; it’s more about breaking the cycle of ‘adverse childhood experiences’.  If the symptoms and ‘disease’ have stayed the same, why should we be changing what we do?  Or do we just say we’re doing different things, and carry on regardless?

Perhaps a more sustainable approach would to be to admit that we’re dealing with a spectrum of issues, with a range of causes and factors.

Providers in the sector are often told to diversify and not be reliant simply on one large contract.  Perhaps commissioners, lobbyists and policymakers could follow the same advice and not be reliant on one big ‘story’?

Monday 10 September 2018

You can't be an expert on your own

After attending EXCO 2018 a couple of weeks ago, I don’t have the answers to what Excellence in the Commissioning of Opioid Use Disorders looks like.  But then I wouldn’t expect to.  In fact, I think I’m giving the conference the highest praise possible when I say that it got me thinking in depth about commissioning and how we do it. 

Any conference has, almost by definition, some element of ‘broadcasting’; people telling a room what they’ve done, and ideally reflecting on what they’ve learned.  But sometimes the most useful part of a conference is the human contact, the genuine sharing of ideas.  In simple terms, a conversation rather than a lecture.  It’s this that sets a conference apart from reading a book or an article, or even watching a webinar. 

EXCO was no exception.  For me, some of the most interesting and useful moments were in conversations over coffee or lunch. 

And I think this applies more widely: there’s a real need for genuine conversations in commissioning.  I don’t necessarily mean sitting over coffee and chatting things through.  This kind of exchange of ideas could be virtual, through online communities (I’ve just joined an interesting group on Knowledge Hub, generally used by local government staff). 

And in fact it’s not just about actual conversations, whether virtual or ‘IRL’.  I’m thinking more of an exchange of ideas.  It was in some ways a point from Annemarie Ward about our sector being in competition that got me thinking again about how we might approach things differently – and that wasn’t part of a conversation so much as her point percolating through my mind on the (long!) drive home from Manchester. 

But writing about how we need ‘an exchange of ideas’ is exactly the sort of thing that generally winds me up.  It’s no wonder that when commissioners like me use this kind of phrase we get told, quite rightly, ‘you talk, we die’. 

But I think it’s important.  It’s about the way we approach our jobs – and without doing this in the right way, we really are in danger of pointless talk. 

What do I mean by pointless talk?  Well, the kind of ‘broadcasting’ I talked about earlier.  Too often, when a group of professionals come together to share ‘best practice’, it turns into a bragging session.  Too often, when an organisation like Public Health England (PHE) or the Local Government Association (LGA) release a guide to something it’s full of ‘case studies’ that are simply puff pieces – opportunities for people to boast about how wonderful their organisation (and, by implication, their own work) is. 

My fear about an ‘expert’ faculty is precisely that: it will become an opportunity for those involved to broadcast information that confirms their status as ‘experts’.  We don’t need another organisation like that.  Instead, we should be more honest and collaborative.  Perhaps if, instead of talking, we made more of an effort to listen, share and cooperate, then fewer people would die. 

I know this sounds rich coming from someone who actively blogstweets and writes, sharing his own views, but maybe it takes one to know one.  I like a bit of attention, and I find it rewarding to feel like an expert, but on lots of things – actually, everything – the attention shouldn’t be paid to me, and I’m not the ‘expert’ voice you should be listening to. 

But what does this mean in practice?  It means that I think the Faculty could be a great vehicle for these conversations.  But I would suggest we need to approach these conversations differently to lots of interactions I see (and participate in!) at the moment. 

(I appreciate it’s slightly odd that I’m stating a definitive opinion at the same time as I’m denying expertise or that anyone has the answer.  I’m afraid you’ll have to live with that.) 

So let’s turn a management platitude on its head: don’t come to me with solutions, come with problems.  If you come to a group with a problem, there’s instantly a conversation.  If you come with a solution, you’re often just grandstanding. 

You might have thought PHE could play this role as a facilitator of conversations, but it’s clear it’s not quite managing it at the moment.  Having heard Rosanna O’Connor speak at EXCO, I wonder if we – local commissioners – are part of the problem.  (Of course we are.)  She made the point (though not in these words) that the sector can look a bit like it’s crying wolf about funding cuts when all the stats still look rosy, because no-one wants to admit that things aren’t going well in their team, their organisation, their local authority.  And if we don’t want to tell them things aren’t working, how can they host open, honest conversations? 

So I think there is a potential role for a Faculty of Commissioning, but while I’d love to be an expert, a person can’t be one on their own.  Perhaps this faculty could be a place to share mistakes and problems as much as ready-made expertise. 

It’s this slightly pessimistic vision that could make me optimistic.  How about you?