Thursday 7 June 2018

New Directions in the Study of Life

I spent Thursday at the annual conference of the New Directions in the Study of Alcohol Group.  This is always excellent, and never the same.  The tone and the themes are always driven by the people speaking and those attending, though it retains an open and forgiving atmosphere towards curious and uninformed people like me.

Throughout the day, there were some common themes that struck me.  I’m not quite sure how I can link them together coherently (or even if I should – perhaps that would be a misrepresentation) but I’m going to do my best here.

(I haven’t mentioned everyone who presented by name, but all the presentations were fascinating, as well as the comments from the floor.  Although I don’t talk about them in detail here, I found the presentations by Tim Leighton and Josie Soutar particularly interesting and useful, as they talked about the practicalities of delivering effective treatment services.  To find out more about the conference, check out #NDSAG2018 on Twitter.)

Although it probably reflects my interests and prejudices, I felt that several of the presentations were arguing against the drawing of clear lines.  If this sounds abstract and meaningless, I’ll give a couple of examples.  James Morris and Claire Melia spoke about the language used by clients and professionals: is it the same, and does this make a difference?  Does the language of ‘alcoholism’ serve to exclude people who would benefit from support just because they don’t identify as ‘alcoholics’?

James suggested that we’d do better to understand problems related to alcohol as being on a spectrum.  This would allow the full range of people who might benefit from help to have a way of talking about their issues, which makes it more likely they will identify these.

Meanwhile, Claire was pointing out that a key element of recovery (and this was echoed by other speakers) is having a kind of ‘in-group’ identity.  That is, people do self-identify as being in recovery, and the social element of this is crucial.

But how are these consistent?  If we take away the idea of a defining ‘disease’, or a clearly defined group with a ‘problem’, and replace it with the idea that everyone is somewhere on a spectrum, how can there be a neat group identity?  What would separate someone who had stopped drinking having had a physical dependency from someone who had decided they were drinking a bit over the recommended limits and did a programme like One Year No Beer?  How could you have a strong in-group identity if we’re all on a spectrum?  Does that matter?

And it wasn’t just the idea of having a spectrum of problems that produced this uncertainty about identity and dividing lines; the same thing could be seen with the potential solution or end point to these problems.  I was thinking maybe there’s a clearer sense of group identity through the treatment process.  Certainly in the field it can feel like there are tribes of fellowship supporters and those who advocate a more cognitive approach, even if it still involves groups, like SMART.

But the discussions made it clear that most people are not actually signed up to a single, coherent philosophy or ideology.  Instead, they behave like magpies in terms of recovery/addiction discourses and ideas, taking a creative and flexible approach and picking up what they find useful and acceptable from any particular approach and leaving the rest.  So as David Best described, you can find people who step out of a therapeutic community and then go to AA meetings, despite the fact that these two approaches have quite different understandings of the nature of the problem a person is likely to be facing, and how this is best dealt with.  This shouldn’t really be surprising.  It’s odd to find anyone whose actions (or stated beliefs) accord precisely with any given ideology or belief system.  Even Marx, famously, maybe wasn’t a Marxist.

But if it’s not about what ‘problem’ you have, or what treatment you’re receiving, perhaps there’s a group defined by where you end up.

The subject of the conference was ideas of recovery, and I wondered whether, if we couldn’t hang onto an in-group identity of recovering from something clearly defined (like ‘alcoholism’) then maybe the key is in the what you’re recovering towards.  This was certainly important for plenty of speakers.  Being in recovery meant making social connections and contributing to a community – and this provides a sense of identity and wellbeing, as powerfully explained by Simon Morgan.

But as so often when this comes up and people try to define it, I was struck by the universality of the concept of recovery.  What I mean by this is that when people spoke about recovery, they were talking about something that could be applied to everyone’s lives, not just people with an identified ‘addiction’ or substance use disorder.

David Best referred to recovery as a search for ‘eudaimonia’.  This is a term from Aristotle that I’ve written about before, and although it’s generally translated as ‘happiness’, it really means something like ‘fulfilment’ or ‘flourishing’.  Recovery, he suggested, represents a shift from ‘hedonism’ (pleasure-seeking) to something more rounded and whole (‘eudaimonia’).

Apart from the fact that I’m suspicious of anything that distinguishes pleasure from fulfilment, given that we can’t as a human race (or even society) agree on what a fulfilling life for a person looks like, this has some wider implications for what recovery might mean and how it might apply to thinking about substance use.  The definitions of recovery being discussed really amounted (as the use of the term ‘eudaimonia’ suggests) to a whole life philosophy.

This raises the question not just whether there’s a tight enough group defined, but whether there’s even any point thinking about substances.  And Tim Leighton pointed out, reporting on his research with staff and service users, that most people don’t talk much about substances in describing what’s good about treatment; they’re more likely to refer to trust between each other and having developed a new set of values and priorities.  A key part of this isn’t thinking about substances so much as finding alternative ways to process other emotions, to change the standard response from being that someone would just pick up a drink to cope with a particular situation.

And here’s the rub: if we’re interested in helping people to lead fulfilling lives, through processes of trust and developing internal conversations, what has this got to do with alcohol?  As James Morris suggested, wouldn’t we all benefit from some psychotherapy?

(And this is before we start to think about how problems where alcohol is implicated often have their roots (and solutions) in issues around employment, housing, education and personal relationships, rather than the simple chemical substance of ethanol.)

So were we all really attending a discussion of New Directions in the Study of Alcohol, or just New Directions in the Study of Life?  I started to wonder whether we’re looking at this right.  If it’s all shades of grey, then why are we so keen to draw dividing lines?

Writing this I’ve remembered my facetious claims as a student that basically everything we study is sociology (well, at least the humanities and social sciences).  History is just the sociology of the past.  English is just the sociology of literature.  Economics is just a specialised branch of sociology.  But all I really meant was these were subjects that were studying people and societies.  Sure, if you take that broad a view it’s all sociology, but what’s the point calling it that?  It’s just semantics and it doesn’t get us further because we’ll probably need to specialise to study these things.

Why are my student pretensions relevant?  Well, the same applies to studies and treatment of alcohol and other drugs.  Yes, we can say it’s all a spectrum and it’s shades of grey, but we’ll still have to draw some lines somewhere.  Those lines will be imperfect – and we need to remain conscious of that and not start seeing them as the truth, or the tail wagging the dog.  But we do need them in some form.

But there’s still an element of this that makes me wonder about how many of those lines we really need, and how permeable they ought to be.  That is, it was noted that in general there isn’t a huge need to separate men and women into gender-specific groups for treatment.  And I’ve always said of our local drug and alcohol services that when alcohol users are persuaded to walk through the door, they tend to get significant benefits from sharing group time with users of other drugs.  It isn’t the case that we always need separate groups.  As Wendy Dossett pointed out in discussion, one of the things people find most useful about having group treatment, and one of the key ways that ‘in group’ identity is formed, is the sharing of shame – of knowing that other people have done the same things you have.

One potential response to this is to say that lots of us have done things we are ashamed of, whether when dependent or intoxicated on a substance or neither.  If we’re all sharing this idea of ‘eudaimonia’ or the good life, and it’s meant to entail human connection, why is it limited to those with substance use issues?  Is the ‘treatment’ we provide really only for those who have a substance use disorder?

I don’t mean to be flippant, and I understand that if we provide something for everyone, we probably provide something for no-one.  And there’s certainly a policy case to be made that having some elements of work ringfenced can be protective, preventing particular workstreams simply being co-opted into a wider mainstream concern.

But all the same, I wonder.  What makes this about alcohol?  What makes recovery something specific to our ‘sector’?  How does it relate to mental health?  And how does treatment relate to housing, employment and personal relationships, which we know are so influential?  And at what point does talking about developing a different way of living, a different way of organising society, stop being a discussion of alcohol treatment and policy and simply become a political project?  Is that what we should actually be doing as professionals – campaigning for a different social and economic structure?  Here’s to New Directions in the Study of Life.

Wednesday 6 June 2018

Is drug testing a public health issue?

Like a lot of people in the field, I’ve been thinking about drug testing lately – meaning the testing of drugs that people might use, rather than people who might use drugs.  A good introductory piece was written in The Times by Hugo Rifkind (with the inevitable response from Peter Hitchens), but although this was presented as encouraging a pragmatic approach, focused on what we can do right now to reduce deaths related to drug use, the reality is that a statement in favour of this approach in principle doesn’t get us much closer to delivering it in practice.

I would say this is where I come in, but actually the most fundamental points are dealt with by chemists, harm reduction workers and the Police: how can people actually get a useful, timely service within the law?  I’m not going to comment on those; The Loop are the experts on that.

What I mean is the other fundamental issue: who is going to pay for this?

This was a question that soon emerged in discussions of how we should respond to the deaths at Mutiny, and my initial response was exactly in line with Max Daly’s (as on many other things).  But since then I’ve had to think in a bit more detail, as it’s become a more real question for us in Dorset with discussions around Bestival, and this is where I’ve got to.

And for me the root of this issue is the question: is drug testing a public health issue?

So here are my not-terribly-original-or-insightful thoughts…

I want to start by stating some of my assumptions.

First, these kinds of facilities aren’t a complete solution to the problems, but they should be available at festivals.  In the absence of drug regulation, these services are the best bet we have for reducing deaths at festivals and elsewhere; if only because they enable better harm reduction information to be put out that the generic comment of ‘there seems to be a bad batch out there, so be careful’ (this is almost exactly the wording used by Mutiny).  People will always think it’s not their batch that’s bad, and if you advise that things are ‘strong’ this isn’t always helpful for explaining how people should behave.

By contrast, The Loop are able to give specific warnings about specific pills – not only to individuals, but across social media.  They also provide harm reduction advice to people there and then regardless of the test results.  How many of these people would otherwise have asked for this advice, or ever have received it?  The answer appears to be as low as 1 in 10 of the people who currently access The Loop’s service.

And there are some good, clear messages available for harm reduction, such as ‘crush, dab, wait’.  Or even, if we want to digest things even further: ‘no-one should be popping whole Es in 2018’.

So if the service works, who should fund it?  Well, in my experience local authorities have tended not to fund the harm reduction and health services at these kind of events previously.  Mostly it’s the responsibility of the organisers to sort that – though the local authority might place some kind of condition on the licence it grants, or offer advice to the organisers.

The only time I’ve got involved in this was when a new festival ran just outside Dorchester, and because it was likely to be a local crowd we made sure that the independent health and first aid team on site had leaflets to signpost people to local drug and alcohol support services – but it wasn’t those services that were providing the support on the day.  And we didn’t contribute directly to the costs of providing the first aid team; in fact, if I remember rightly, the festival organisers gave free entry to some local authority staff partly so they were on-site to see how things were progressing, and partly as a gesture of goodwill.  So if anything it was the organisers that would have been contributing, rather than the local authority.

But that’s only the past, or convention.  What should the local authority be contributing?  Well from my perspective, I’d be happy for local services to be on site and offering advice and information to either/both the health and first aid teams and the public directly.  These services are commissioned to be open to anyone in Dorset, and they should be going out to where people who might need support actually are, rather than waiting for them to walk through the door.  A local festival seems like a pretty good bet for this to me.

The thing is, The Loop already offer this kind of support as part of their comprehensive package, and so I’m not sure whether local services going into festivals would be efficient or appropriate.  But that’s just an operational question.

The involvement of the local authority in terms of harm reduction (as opposed to emergency planning, licensing etc) isn’t likely to be in direct provision so much as answering that question of money.

If we’re imagining a local public health team might fund this from their substance misuse treatment budget, I suggest we think again.  Will this be an efficient, effective and equitable approach?  Will it narrow health inequalities?  I think that’s hard to sustain, particularly at a time when we’re having to cut services that help reduce drug-related deaths in greater numbers – that is, opiate substitution treatment, which helps reduce opiate overdoses, which remain by far the most significant category of drug-related deaths.

At a time when we’re not prepared to take the legal or financial risk of publicly introducing a drug consumption room in an English local authority, and local politicians still oppose treatment being provided in areas that needs it, I find it hard to look at the positivity around drug testing at festivals without thinking back to my academic background of reading Bourdieu and thinking about distinction.  Are some drug users more deserving of investment than others?

Any money spent on drug testing will have to be taken from a treatment budget, and could mean one fewer member of staff in a service.  I understand that the costs of running a service like this somewhere like Bestival would be around £20,000.  This is not insignificant for a local budget.

It might be different if we were talking about an offer in a town centre, as part of the broader work to ensure that the night-time economy is as safe as it can be.  But this is a private event, on private land, with paying customers.  It’s not entirely clear why this would be the local authority’s responsibility.

That isn’t to say, of course, that this isn’t a public health issue, though.  And perhaps I’m just being defensive because I know the financial constraints we’re operating under.  Maybe it’s not fair to pit one group or issue against another, even if that’s how politics and policy work in practice.  It might still be something we should be providing, even if we can’t easily do that at the moment.

So let’s think in more detail about whether this is genuinely a public health issue, and what that means for who should be stepping up to be counted.

I want to make an analogy with the selling of unregulated products in the nineteenth century (or earlier).  The state wasn’t, as in Hugo Rifkind’s eye-catching analogy, actively poisoning burgers to reduce obesity, or allowing people to drink paint thinner as a warning against alcoholism.  Rather, people were putting their own health at risk by eating meat and drinking water they knew was risky, because there was no real alternative.  It was all they could get.  No-one was making a rational choice, Friday Night Dinner style, to eat rotten meat.

(I should point out here that I am not a historian of public health, so I’m making a point about the principles more than the details.  But please correct me in the comments if I’m wrong on something substantive.  If the analogy isn’t good, it’s got to go.)

In these circumstances, the appropriate public health response is not to ban all meat, or suggest people only eat vegetables; it’s to regulate the food industry and ensure that they only sell safe products that are accurately advertised.

Of course, MDMA does not occupy the same place on the hierarchy of needs as food and water, but if we’re thinking of pragmatic policy, there’s little doubt that (a) while not every human enjoys intoxication, it is unrealistic to imagine a human society where this impulse does not manifest itself in some way for a significant proportion of people; and (b) the substances that are being used cannot be undiscovered or uninvented.

And actually we’re not talking about all food or drink; it is possible to live as a vegetarian, so why not just say that meat-eaters should look out for themselves.  Meat is a luxury and ‘caveat emptor’.  It’s the customer’s choice to buy meat, so it’s their risk and duty to check it’s safe.  If they’re not happy with the risk, they should stop eating it.  It’s no-one else’s fault if they fall ill after eating it when they could just have had a nut roast like some other people.

But that isn’t the public health response to unsafe meat.  So what should its response be to unsafe drugs?

Well, we can lobby as individuals or as a group (and the Royal Society for Public Health has done this), but in the immediate term we have to operate in the current situation – which was Hugo Rifkind’s primary response to Peter Hitchens: given we can’t change the situation regarding supply today (whether to further restrict it or regulate it), what should we do right now?

Well in the absence of any proper regulation for these substances, which means we can’t stop people being sold substances of questionable quality, all we can offer is a service to consumers to test the product they’ve brought.  Not everyone will use this, and not everyone will respond to what they’re told in what we might consider a ‘rational’ way, but it’s hard to see what other options there are.  Of course more people will use this service if it’s free.

So I’ve stated that drug testing is a public health issue, and there should be free testing for it.  So shouldn’t the local authority be funding testing at Bestival?  Is the only reason not to the austerity levels of funding available?

Well let’s think about that meat example, even if it is a bit tenuous.  The state doesn’t pay for free customer testing of meat.  Rather, it relies on producers to ensure quality and safety, with the understanding that there will be periodic tests and the costs of ensuring safety will be passed on to the customer in the price.

Thinking of another example, health and safety inspections occur, but we expect leisure centres to be responsible for ensuring the safety of their swimming pools.

By the same logic, the onus for testing at a private event on private property shouldn’t be placed on local authority public health teams, and festival organisers should ensure harm reduction measures (the equivalent of lifeguards, safe water, rubber rings) are available and accessible.

Following these analogies, we can imagine a situation where the local authority did some trading standards style spot testing, but this isn’t possible under the current legal framework (though interestingly it was appropriate while there were still ‘legal highs’ before the Psychoactive Substances Act).

So that’s the answer to the question that no-one (apart from me) asked: drug testing is a public health issue, but that doesn’t necessarily mean that local public health teams should be funding it.  Now let’s get on with trying to encourage a more coherent approach to regulating these substances so this kind of discussion becomes redundant.