Wednesday 28 March 2018

What are drug consumption rooms for?

I’ve been thinking a lot about drug consumption rooms lately – often referred to in the field as DCRs.  They’ve been an issue nationally, with the debates around the Glasgow proposal as well as noises from Durham and other places.  And it’s no secret that drug-related litter has been an issue in Bournemouth and Weymouth, which my job covers, so it’s a day-to-day thing too.

The arguments are pretty familiar.  There’s not any real doubt that these facilities can have a positive impact for people who use drugs and the wider community.  However, there’s a debate about the scale of that impact and whether scarce resources are best spent on these kinds of facilities rather than other, more established, initiatives.  We’re never going to live in a utopia where everything that everyone needs or wants is funded and so these questions are real: what would we be trying to achieve with DCRs, and would it be worth it?

(For those of you who don’t follow these debates in as much detail as me, the term DCR can cover a range of things, but generally means somewhere to inject drugs under supervision.  The arguments in favour are that they reduce risks to people who use drugs as they have somewhere cleaner and safer, where someone is checking that they’re OK – but it’s not just about the users themselves, as they can potentially reduce public use and drug-related litter as well as drug-related crime.  If you want a good summary, Glasgow and Southampton councils have done great work on this.)

The view of the ACMD is that DCRs might be useful, but as part of a wider package of interventions; they shouldn’t be seen as a panacea on their own.  That is, of course, fair, but it’s not the most practical advice for commissioners who are struggling with increasing numbers of drug-related deaths, an ageing cohort of people who aren’t making great progress in treatment, and rising rates of homelessness and public injecting.  A comprehensive package of interventions would be great, but we didn’t have that in 2010, and now we’ve got cuts of 20% already, with no funding at all guaranteed beyond 2020.

So can – or rather should – DCRs be part of the picture in terms of commissioning under austerity?

When this debate comes up, it’s often framed in terms of the ‘methadone wars’ – that harm reduction has been sacrificed on the altar of ‘recovery’.  But (and I’m not alone on this, it’s not an original thought) I can’t get my head around this invented binary.  How does anyone achieve recovery without reducing the harm from their substance use?  How can giving someone advice and information about substance use be counterproductive to them achieving recovery?  Or, putting it bluntly: you can’t recover if you’re dead.

And a lot of people who use drugs are dying.  I don’t think this can be overstated – though it’s not necessarily the most powerful political argument in favour of drug treatment.

But setting aside this idea that treatment has been damaged by a focus on recovery or ‘successful completions’ (which I appreciate is some people’s experience, but it’s not mine), if we’re coming at this issue fresh, without the baggage of previous political debates, what should we do about DCRs?

Well the first point I often hear is that we should (to reference John Major) get ‘back to basics’.  If only we did needle exchange (and possibly opiate substitution treatment [OST]) properly, then there wouldn’t be these issues.  I’m informed that we’ve lost specialist needle exchanges and pharmacies offer a poor replacement.

But I don’t recognise this picture.  Commissioners find contracting with pharmacies frustrating: there’s lots of them and their local authority ‘business’ (whether needle exchange, supervised consumption of methadone or sexual health services) is a fraction of the overall turnover from NHS England or the commercial side of their work.  You can’t effectively manage a hundred contracts of this type.  The provider doesn’t care about your element of the service that much, and as a commissioner you can’t spare the time or energy to manage each one of them with the same intensity you’d apply to a specialist provider.  So inevitably the service isn’t great.

But that’s no criticism.  In fact, it’s in line with NICE guidelines, which suggest a tiered approach to needle exchange where specialist services offer the gold standard, including harm reduction advice, but we can’t provide that in every neighbourhood and indeed this level of involvement might put some people off, so we need to offer accessible facilities in a wide range of locations too.  It wouldn’t be possible to have a specialist needle exchange in every town or village in Dorset, but it’s possible to deliver this through pharmacies – though inevitably at a lower level of intensity.

I just don’t recognise the picture I’ve seen (or rather heard) painted that commissioners have lost all the structure and experience of 30 years ago, seen as the heyday of harm reduction.  Maybe it’s true elsewhere, but although we’re always able to improve our needle exchange offer, and the past few years haven’t been ideal, I can’t see that we’re moving away from specialist services to pharmacies.

If anything, as I say, I would have thought that the public health experience of having to directly commission pharmacies to do all sorts of bits and bobs that you wouldn’t have thought were the local authority’s responsibility (the morning after pill, for example) would have made commissioners more reluctant to use this as some kind of efficient escape route from the problems they’re facing.  There’s more uncertainty and less control – how’s that a recipe to sleep easier at night?

The issue is more likely to be integration – not only between pharmacies and the wider treatment system, but simply between needle exchange and more structured treatment.  I’ve been told that many service users actually prefer using pharmacy needle exchanges to the specialist services -precisely because they don’t get those hassling harm reduction initiatives or people trying to engage them into ‘structured’ treatment.

And that’s where we get to a really difficult point.

DCRs are often sold, following the ACMD argument, as an opportunity to engage people into treatment.  A DCR can be a hub for the full range of harm reduction activities and wider social interventions like housing, benefits, employment, probation and so on.  The argument is that some of the people most in need of support are going to come into this facility, so it’s an opportunity to get a whole range of ‘wrap around’ services put in place as part of a broader treatment ‘plan’.

But most DCRs aren’t just harm reduction hubs; they also offer – for example in the Glasgow proposal – structured treatment, often heroin assisted treatment.  Certainly there’s all sorts of services operating from most, from methadone dispensing to housing benefit advice.  That can sound like a great idea; an opportunity to engage people straight from injecting illicit substances to being on a legal prescription.

But equally it can sound like the opposite of what some harm reduction advocates would hope.

In Weymouth, we have brought all our services under one roof.  There used to be a site for prescribing, a site for harm reduction and group work, and a site for the criminal justice team.  And then the abstinence-based ‘aftercare’ operated from a range of sites (like church halls) that weren’t permanent fixtures.

(It’s not just austerity that brought services together; it’s also service user feedback.  One (unnamed) individual used what’s become known locally as ‘the dentist analogy’: imagine if you had to go one place to have your anaesthetic, then walk down the road to get your tooth drilled, then hop on a bus to then get the filling actually put in.  That’s what dealing with substance misuse treatment (and all the other related services) felt like to them.  Saving on rental costs by sharing premises won’t dig us out of our financial hole; one member of staff can cost more than the rent on a workable building – just check rightmove.  It’s the people that make the difference in services, and quite rightly that’s what commissioners are mostly paying for.)

So what’s the problem with bringing services under one roof, as they would be to some extent with a DCR?  Well, it means that by definition you don’t have dedicated harm reduction services; they’re operating from the same premises as the prescribing provider who will be (more often than not) part of the NHS.  So our needle exchange now operates from the Weymouth Community Hospital site.  Since it moved from a dedicated third-sector ‘drug agency’ base, the numbers accessing needle exchange there have fallen.  People, we’re told, find it intimidating to access needle exchange at the same site where they pick up their prescription.  (And equally, people who are now abstinent find it a challenge to step through the door of a facility where people are still in ‘active addiction’.)

I appreciate this is rambling.  I haven’t got (as I often ask for in the day job) a clear definition of ‘the problem’ or a proposed ‘solution’.  But that’s the point.  A lot of people (including me) are excited by DCRs, but if I’m honest that’s partly because they’re shiny and new to a UK audience – and therefore untainted and full of promise.

On this blog I’ve often moaned about how minimum unit pricing for alcohol is an empty vessel into which people pour all their (alcohol policy) desires: it’ll stop underage drinking, binge drinking, dependent drinking, excessive everyday drinking, and so on.  It’ll even revive the pub trade.

I worry that DCRs will become the same thing for drug policy: they’ll reduce drug-related litter, public injecting, blood borne viruses, crime, antisocial behaviour, and they’ll foster recovery and abstinence while they’re at it.

Will DCRs really be a harm reduction hub?  And if they are, should they also be a site for delivering treatment?  Or will that scare people off?  (Both people who aren’t ready for treatment and those who want to see a bit more stability in their lives.)  To return to my regular themes on this blog, I think we need to work out what we’re trying to achieve before we start leaping to solutions.

Friday 23 March 2018

The future of Alcohol Research and Concern

Alcohol Research and Concern are, as you'll probably be aware, merging, and they're currently conducting a consultation on various aspects of their work to think about what the shape and aims of the new organisation might be.  They will be inviting comment on specific issues and questions and I'd really encourage people with any interest in alcohol-related issues to comment.  Here's what I wrote on treatment (you can access the original post by Richard Piper asking for feedback just by going to the home page of either organisation):

In terms of the specific questions you ask, yes I think there’s the potential for greater private/charity involvement in delivering to a wider group of people without addition state support.  Certainly our services (deliberately) focus on areas of greatest socio-economic need, so there may be opportunities to increase charity donations or encourage people to contribute to their own treatment or intervention – even if that’s just paying to download an app.  But this has (at least) two potential problems: (1) how do you ensure that it’s only those who can afford to pay that feel they have to; and (2) are you OK with this position politically/ethically in terms of diluting a commitment to universal healthcare free at the point of use?

As to whether the charity should seek to influence government, I think it’s perfectly reasonable to campaign for greater use of evidence-based programmes.

In terms of innovation, there’s not only technical stuff but also more general evidence that could make services more efficient and effective.  This means not just encouraging people to go online but also viewing their issues as part of a wider life, especially thinking about family, employment and housing.

Families can of course be crucial to recovery, as other respondents have emphasised, but there are plenty of people who are at risk who don’t have accessible or supportive family networks: family can be absent or indeed as much a part of the problem as the solution.

And while taking ‘a whole family approach’ is the current popular phrase for PHE and local authorities, this is often at root about reducing costs for children’s services.  I’m suspicious of this instrumentalism, given the experience of New Labour and the NTA failing to achieve sustainable acceptance of drug treatment using crime as a fig leaf for what was really about providing health and care to a group of people in need of support.  So there are key dangers with focusing on ‘family’: first, the neglect of drinkers who don’t live with children; and second the pathologising of all parental drinking, or at best painting it all with the same brush when in fact there are myriad problems where alcohol is implicated.

And this is the key point: although the Alcohol Concern/Research charity will inevitably be focused on alcohol – and this is reasonable as it is a specific and unique substance with its own history and policy – people relate to this substance in an infinite number of ways, in connection with everything else in their lives, and therefore any analysis, policy or treatment cannot and should not focus on an ‘alcohol problem’ that the UK has.  Alcohol may play a role in people’s problems, but that’s something quite different.  Even dependence is hard to isolate as a uniform condition, and certainly its implications vary.  It may or may not be seen as part of a wider ‘substance use disorder’.

And so my plea would be to avoid discussing ‘alcohol treatment’ as a monolith (when there will be a range of issues, and solutions must look beyond alcohol) and not to equate this with something that is designed to address ‘dependence’.  But you and your colleagues know all this already.  Good luck!

Saturday 17 March 2018

Can alcohol policy accept moderate intoxication?

Having recently finished a draft of what will hopefully become a book chapter on the Psychoactive Substances Act, I’ve tried to clear my desk out this weekend, and came across all sorts of incoherent pencil notes on scraps of paper that were intended to be transformed into blog posts.  One of them, however, stood out.  It’s not fully formed, and it would need a lot more work to become coherent and worthy of proper publication, but it’s exactly that kind of half-baked, incoherent rambling that’s the hallmark of this blog: thoughts that aren’t neat (or long) enough to become academic articles (or perhaps even conference papers).

So here goes.  This should probably be read in tandem with my previous ramblings on the Psychoactive Substances Act, given that I think this was an earlier version of the chapter I’ve ended up putting together – or perhaps a response to it.  (I've updated mentions of the Psychoactive Substances Bill to 'Act', as it passed some time ago now.)

I think it also works quite well with a book I'm reading at the moment by Ingrid Walker.  Go buy that!

Before I start, I should state a key assumption: we’re never going to be able to pin down what the government is concerned about in relation to drinking (alcohol) into a single idea, like ‘pleasure’, ‘disorder’ or ‘intoxication’.  My previous attempt (with the ‘carnivalesque’) is a bit of a cheat to put together a whole ragbag of things (excess, disgust, class, gender, etc) and doesn’t tell the whole story even then.

As James Nicholls and others have argued, alcohol tends to become a lightning rod for broader social and political questions to be played out: freedom, agency, morality.  I saw a good example of this at the Alcohol and Drug History Society conference in 2013, where in the same session different presenters described British and French attitudes to women’s drinking in the nineteenth century.  Lauren Saxton described how the French, who were worried about underpopulation, seeing themselves as slipping behind other European powers in a kind of population arms race, expressed concern that drinking led women to be infertile, or at least to have fewer children.  Presentations from Thora Hands and Stella Moss, (on Twitter here and here) showed that the British, meanwhile, were concerned by overcrowding in cities and people’s inability to feed their families, and saw alcohol as leading people to have more children then they would otherwise – with less money to spend bringing them up because they were spending it on booze.

Previously, I've been somewhat dismissive of the idea that government has been 'criminalising' pleasure and/or intoxication, arguing that this doesn't quite capture the specific concerns it expresses in relation to 'binge' drinking.  But, as that example shows, this is because my focus has generally been on alcohol policy, where I think the situation is more complicated because of the legal status of alcohol in Britain today.  The situation is different when we look at other substances that might be grouped as 'intoxicants'.  And I think, grouped in this way, we can start to see a common thread between all of them, despite initial appearances.

The new Psychoactive Substances Act [not so new, now I'm typing this up] is precisely targeted at intoxication, and tries (pretty clumsily) to pin down a scientific description of 'psychoactivity' to do this.

In the same way, successive alcohol strategies have been targeted at those who 'drink to get drunk', also known as 'binge' drinkers.
Now this needn't imply opposition to intoxication per se, and there are certainly other societies past and present where certain limits to intoxication have been applied (rather than absolute opposition to intoxication).

We can see this in Jennifer Richards' rejection of the approach based on Norbert Elias' concept of a 'civilising process' that sees early modern writers as giving drinking advice based on opposing ideas of 'excess' and 'restraint'.  According to Richards, 'the preoccupation with restraint and excess has left the conviviality of moderate intoxication, light-headedness, and its rhetorical practice - the witty adaptation of sayings - overlooked and undervalued' (p.172).

This view would be very familiar to the drinkers of many research studies, whether the young women described by Farringdon as trying to tread a 'fine  line' of feminine drinking, or the older drinkers in Carol Emslie's work.

But today's UK government cannot see alcohol consumption or use of any other 'drugs' in these terms.  Alcohol strategies don't talk about 'fuddled joy', for example, and the alcohol industry is not allowed to suggest that drinking enhances sociability - something that many of us would struggle to argue with.

Alcohol as possible health-enhancer, alcohol as tasting good, alcohol as a valuable part of the UK economy, yes.  'Moderate intoxication'?  This, in alcohol policy debates, seems to be considered an oxymoron.  The phrase is surely unimaginable in a policy document.

The government, if no-one else, is still very much signed up to the Norbert Elias model of good and bad drinking as being about restraint versus excess, where any intoxication - or at least 'drunkenness' - is by definition excessive.  The 2012 Strategy noted that 'in moderation, alcohol consumption can have a positive impact on adults' wellbeing, especially where this encourages sociability' - but the example of how this happens has nothing to do with the 'intoxicating' or 'psychoactive' properties of the substance: 'Well-run community pubs and other businesses form a key part of the fabric of neighbourhoods, providing employment and social venues in our local communities' (p.3).

(Of course, in acknowledging the setting of drinking this government, like its Labour predecessor, was showing it is familiar with the important work of Norman Zinberg.)

This approach, whereby 'moderate' and 'safe, sensible, social' drinking cannot mention intoxication does suggest that government is concerned with mind alteration specifically.  But actually the awareness of the importance of setting and so forth reminds us that the concerns are indeed broader.  Psychoactivity gives a neat rationale and pseudoscientific position, but in reality the concerns are about things like crime and antisocial behaviour - or more widely the disruption of everyday norms (see my work on the carnivalesque where the concerns are more about 'norms' being disrupted then chemical intoxication).  The Psychoactive Substances Act effectively brings this position out into the open, by separately, as explicit exceptions, those substances that are viewed to have forms of consumption consistent with those 'everyday' norms: alcohol, nicotine and caffeine.  But even then: 'moderate consumption', yes (though not even that in terms of nicotine), but never 'moderate intoxication'.  Here's hoping for a shift in the narrative.