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’?
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