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?