Licences for heroin?

Two (not particularly recent) articles by Keith Humphreys, former White House drug policy advisor, caught my eye last week.  I’ll be blogging about them separately, as they’re not particularly related.

First, as I’ve been thinking about drug policy over the last week or two, I was interested in the idea that heroin overdoses – or those relating to opioids more generally – aren’t actually to do with the relative purity of street heroin.  This is one of the key planks of legalisation campaigns: users will be safer when they know what they’re consuming.  I’d say this argument still holds, given the discussion of deaths related to ‘legal highs’ in my previous post, particularly the idea that PMA might be implicated in many of these, and few people are deliberately choosing to consume this drug.

However, this raises questions for my current view on drug policy, which suggests that, at least in an ideal world, we’d have something not too dissimilar from the legal but highly regulated market advocated by Transform.  Since I started working for a DAAT, I’ve felt (possibly unreasonably) that sometimes while the arts might sometimes have been condemned for celebrating drug use, academics have sometimes abstracted it such that the associated problems seem to disappear.

Those from Transform would probably argue that most of the problems associated with drug use are the result of the criminalisation of possession and supply, and I’d largely agree, but I have a separate fear.

I fear that if drug other than alcohol, tobacco and so forth were legal, I’d be more inclined and able to use them than I am now.  That might not be a bad thing – if I substituted cannabis and ecstasy for alcohol, or a low dose of amphetamine for coffee.

I’ve been wrestling with the idea of overdose, though, which would be highly unlikely in any of these cases.  You could respond by pointing out that alcohol is legal and yet plenty of people ‘overdose’, but that’s not a justification for opening up the door for another drug to do the same.

A certain liberal mentality wouldn’t have a problem with this: if the overdose risk comes from taking too much or mixing with other drugs, and everything’s clearly explained and labelled, it’s simply a poor decision by that individual.

However, the Darke and Farrell paper cited by Keith Humphreys suggests that quite a lot of us are that poor at making decisions regarding opioids (possibly because we get addicted to them, which – for my money and Mick Bloomfield’s – amounts to more than simply an ingrained bad habit).  Addiction, if it means anything, means someone isn’t great at decision-making, particularly when that specific substance is involved.

This is the old debate about liberalism and drugs, brilliantly covered by James Nicholls in relation to alcohol here and here (and which I’m going to post about soon again).  I won’t do full justice to those issues here, but suffice to say I think that in principle there’s no reason the government shouldn’t intervene in this sort of situation, and regulate or ban certain substances.

Maybe the answer, though, isn’t as complicated as it seems.  As some harm reduction advocates never tire of pointing out, there’s never been an overdose death in a supervised consumption room.  We sometimes forget the different ways alcohol is regulated (for consumption on and off the premises), and that these could be tweaked and applied to drugs.  Most advocates for legalisation tend not to forget this.)  And the regulation of all drugs wouldn’t have to be identical – we currently regulate caffeine, alcohol and tobacco very differently from each other.

So perhaps the solution is relatively simple: for drugs where there is a notable risk of overdose, consumption would have to be on-premises, but for other substances, off-licences could be developed.

Of course the argument could be made that illicit opioids would continue to flourish, because people would want the hit without the medical setting – but then again logic suggests licence design could be based simply on the safety of the facility, not levels of comfort and welcome.  Think of CCB or ‘improved’ pubs, which were designed to be respectable and comfortable in order to engender a certain culture in relation to alcohol consumption.

The problem is that such an approach does feel like it would encourage opiate use, which I’m just not entirely comfortable with.  The approach of these sort of schemes is that the state sanctions consumption, but with a certain level of austerity, or restraint.  Although I am strangely attracted by such schemes, I’m not convinced they’re effective or sensible – particularly in relation to certain drugs.

And this ‘feeling’ is actually important.  As Virginia Berridge points out, whether we like it or not, we start from a particular cultural and historical setting that affects how different drug policies are viewed – and in fact how they would be responded to – not only by politicians and the media, but (potential) drug users, who are not acultural rational automatons.

It turns out, then, that one quick blog post can’t resolve this complicated issue.  Never mind, there’s always the new guide by Transform to read.  Maybe that’ll give me a few more ideas.

Ambitious for an informed debate

It’s hard to convey quite how frustrated I was by Sunday’s Centre for Social Justice report on alcohol and drug treatment – and quite how much of a gift for this blog it is.  I won’t really do it justice in this post, as there’s so many gaping holes and misleading inaccuracies in it that I can’t begin to address them all here.

It’s worth mentioning in passing, though, that the much-trumpeted idea of ringfencing an allocation of alcohol tax for rehab could be counterproductive.  The likelihood is that this would come to be seen as the funding for alcohol treatment, meaning that current allocations might be dropped – certainly by local authorities keen to raid public health budgets to ease the pressures of the graph of doom.

There are two key issues I want to focus on here, based on the prominence given to them by the press release and CSJ reps in their media appearances.

First, that residential rehabilitation is the only way to achieve ‘full recovery’.  This sort of argument hinges on one’s preferred definition of recovery, and the adoption of this buzzword in the 2010 Drug Strategy and subsequent Strang Report just papered over the cracks within the sector: the ‘methadone wars’ are far from over.  As DJ Mac suggested, the way the report is written is hardly conducive to the dialogue and persuasion that would be required to genuinely transform drug treatment successfully.

Almost more fundamentally, though, the report presents a conclusion without any basis in evidence.  The only reference for the effectiveness of res rehab is the 2012 NTA report The role of residential rehab in an integrated treatment system, but this largely endorsed the position of most local authorities in using res rehab for a minority of individuals.  It even stated: “For every ten people who go to rehab each year, three successfully overcome their dependency, one drops out, and six go on to further structured support in the community.  Of those six, two overcome dependency with the help of a community provider, at least two are still in the system, and at least one drops out.”  That is, res rehab is not some magic, universal solution, and in fact often treats those who are more stable to begin with – the most challenging and chaotic are those who drop out, and it’s community treatment services that are left to manage them.  Rehabs, the NTA report said, are better at treating those with alcohol dependency than drug addiction – but then this is true for community services too.

There is no doubt that even a six month stay in a res rehab, if successful, is a better option than 10 years on methadone in the community, but it’s not immediately clear that this is a direct choice funders, commissioners or service users can make.  As DJ Mac argued, we do need a debate about how drug and alcohol treatment services should be organised, but it needs to be constructive.  It’s not just that the press release was confrontational; I heard Chip Somers promoting the report on Radio 5 (43 mins into the link) claiming that it’s basically impossible to get state-funded rehab at present and there are waits of years.  I just don’t know where this is true.  There is something of a ‘postcode lottery’ in the sense that policies will be locally-determined, but many facilities would count up to half of their clients as state-funded, and not all local allocations for res rehab even end up being spent.  This is just not as simple as there being a local (or national) policy block on accessing such services – and that’s if we even accept the effectiveness of such services in the absence of clear evidence.

Second, the report makes some big claims about drug-related deaths, which were picked up on by the media.  The first thing to note in this respect is the big picture: whether we’re looking at general drug poisonings or the subcategory of ‘drug misuse’ deaths, it’s very hard to argue that we’re seeing anything approaching a crisis:

Source: ONS, 2013

(I should point out that this second graph is from the 2013 St George’s report on drug-related deaths,  because this is what’s cited by the CSJ in theirs, and that’s what I’m working from throughout the rest of this post.)

More than this, however, the analysis given is just cherry-picking to illustrate a point.  Last year, the CSJ was concerned about the growing number of deaths involving methadone – and this surely still underpins their opposition to opiate substitution treatment, expressed in the latest report.  What they’re concerned to do in the report is paint drug use as a continuing major problem despite declining use of heroin.

NPS (new psychoactive substances) are the particular choice for this report.  If you were cynical (unlike me) it might occur that this is a useful focus, because it’s so difficult to predict how use of and harms from these substances will develop in the coming years, making panic-inducing speculation possible.

Certainly, deaths related to NPS have increased, and the CSJ focuses on this, hence all those headlines about NPS deaths being about to overtake heroin.  The thing is that their analysis doesn’t improve our understanding of the situation regarding substance use in England today.  In fact, it could be argued that it is actively misleading.  NPS deaths are compared with those from heroin and morphine – but why not opiates as a whole, if methadone-related deaths were such a concern last year?  It might be suggested that pointing out the decline in methadone-related deaths wouldn’t fit with the big narrative based on how terrible methadone is, given that last year’s figures relating to heroin and methadone appear to have been an anomaly.

The crucial thing to note here is that the opiates are the single most common psychoactive drug group associated with deaths.  In fact, heroin and morphine deaths accounted for a higher percentage of the total in 2012 than 2011 (by 5.1%).

As an aside, I’m talking about drug-related deaths, but it’s worth pointing out that when the CSJ talks about drugs causing deaths, they have a tendency to count the cases where particular drugs were noted in the toxicology report, rather than where a specific substance was listed as a cause of death.

First off, the CSJ uses just four years of data, covering 2009 to 2012, so long-term trends might not be apparent.  More than this, though, for their extrapolations they only look at two years compared, taking the change from 2011 to 2012.  In the timescale of legal highs this is quite a while ago, and just one year in what could be seen as a rapidly changing field.

I say it could be seen as a rapidly changing field, because if the CSJ had conducted the same analysis last year, rather than noting a 43% increase in deaths were the individual had NPS in their system, they would have seen no change at all.  Both 2010 and 2011 saw 68 post-mortem toxicology reports citing NPS.  (An increase could have been argued if ‘cause of death’ were considered as the key variable, however.)

You could say it would be hard to predict next year’s figures based on a line of development like this:

That’s precisely what the CSJ report did though, and what was picked up by the news headlines.  The supposedly newsworthy comparison, as I mentioned above, was with heroin and morphine deaths.  Initially, it’s hard to see how the NPS deaths would outstrip the others:

However, the extrapolation on one year produces a convergence:

There’s an interesting choice made here: the extrapolation isn’t linear; it’s exponential.  That is, there’s compound interest on the increase, such that if NPS deaths carried on increasing in this way although the figure of 400 seems believable for 2016, it’s hard to imagine 1,166 in 2019 or 1,663 in 2020.  This isn’t to say these figures aren’t possible, but there’s no explanation as to why just one year’s change is taken as opposed to an average over the period, and why this is then compounded rather than treated as a linear function.  The strangest thing about the whole process, though, is that actual figures for 2013 are due out on 3^rd September.  We don’t have to predict; we can know.  Why not just wait for a couple more weeks to make the estimates more accurate?

However, there is no doubt that whether we look at the ‘toxicology’ or ‘cause’ figures, there has been a rise in ‘NPS’ deaths in the period.  What isn’t so clear is whether these are due to what most people would think of as ‘legal highs’ – or indeed whether the substances would be covered by the interventions later proposed.

The increase in toxicology figures from 2011 to 2012 (on which that extrapolation is based) wasn’t down to mephedrone, or anything ‘legal’.  In fact, the bulk of the increase was down to PMA.  Toxicology reports citing PMA rose from 5 in 2011 to 19 in 2012.  But PMA isn’t a novel substance, having been available at least by 1970, and a Class A substance in the UK since the Queen’s Silver Jubilee.  It seems to generally be sold as ecstasy, so it’s not even that users understand it to somehow be a ‘legal high’.  That is, these deaths have little or nothing to do with head shops, as far as we can tell – and yet the recommendations of the report relating to ‘legal highs’ focus on head shops.

Another category of drug that rose was benzofurans – from 1 to 9 – and methoxetamine – from 1 to 6.  Both of these are now illegal (though in the case of methoxetamine, only since 2013 – after the period covered by these data).

Given that the concerns expressed regarding ‘legal highs’ are how to police ‘head shops’, and it would be quite straightforward to stop head shops selling any of these substances, I’m not sure how the concerns and proposed solutions fit the identified problem.  Of course, it might be that head shops continue to pose problems, simply with a new set of drugs – but the CSJ report would have to explain why that’s likely to be the case.  It would probably need new data that illustrate how things have developed since the banning of the relevant substances (and indeed how banning makes any difference whatsoever, given the apparent importance of PMA), and should acknowledge that comparing just two years’ data isn’t the most secure basis for an extrapolation.

Both issues – of NPS deaths and residential rehabilitation – highlight my concern about not just the tone of the CSJ report but its basic accuracy.  We do need a constructive debate, and that requires not only open dialogue, but clear, honest discussion of the evidence.  The CSJ report offers neither, which is at best disappointing.  At least it keeps me busy though.

Budget day and the de-normalisation of drinking

I started writing this post thinking it would be the opposite to most of what I write on here, which tends to be material that – with a little more evidence, research and finessing – I think could be turned into academic work.  However, by the time I was a decent way in, I realised that while this was journalistic speculation, it was inevitably tainted with the overthinking and reliance on abstract concepts that characterises my academic work.  So apologies for that.  I’m hoping that it might still have something of interest in it.

For some reason, on Thursday morning I was reminded of a particular clip in a news item about Ken Clarke’s sacking in the Cabinet reshuffle.  He was drinking whisky while giving the Budget speech.  Drinking alcohol on this occasion isn’t actually unusual; in fact, it’s traditional.  Disraeli drank brandy and water, while Gladstone preferred sherry and a beaten egg (not to my taste, I have to say).  This changed when Gordon Brown was Chancellor, and neither of his successors has dared break with his example of drinking water.

This single example could be seen as very particular, and driven by one specific individual with his own history, preferences and fears.  However, it fits with broader trends.  Phil Mellows has written about the demise of the lunchtime pint, and I’ve experienced this even in the time since my first office job in 2005, when alcohol was happily drunk at lunchtime meals.

On Wednesday, I realised how much I’ve internalised this new norm.  I went for lunch at the (CAMRA-award-winning) local social club (the Colliton Club, which is in the building used as the model for Lucetta’s house in The Mayor of Casterbridge).  Although I’m often tempted by the thought of lunchtime drinking when I see the range of beers on offer there, I was genuinely shocked to see orders for beers and wines being made by a group of people dressed smartly enough to be staff on their lunch break.  They probably weren’t at work, as lunchtime drinking is so frowned upon, but the point is that my automatic reaction was, bizarrely, one of shock.

This is a reaction that sits oddly with the common conception that alcohol has become more normalised in British society – that it’s available at school discos and fêtes, or while you’re having your hair cut.

Although it’s hard to argue that the postwar period was one where Britain had a wonderful relationship with alcohol (despite lower rates of liver disease, drink driving deaths were much higher) there are aspects of this culture, which included the lunchtime pint, that aren’t too bad.

To understand this, I’d like to invoke my pet concept, the carnivalesque* – though actually this doesn’t tell the whole story.  Although it’s often said that Britain is a nation of incorrigible boozers, in fact not only do national drinking patterns change significantly over time, but alcohol can be understood in a range of ways depending on the context.  So, the Christmas at Blackpool drinking described in The Pub and the People is very different to the everyday drinking that those same people did on a regular Wednesday evening.  The lunchtime pint – or Budget whisky – is quite different from the Friday night Jägerbomb.

Or is it?  I’d suggest that one of the reasons we see lunchtime drinking as odd now is that current public debate can’t handle the distinction.  The lunchtime pint is seen as a step towards oblivion.

This is partly the unavoidable result of drink driving campaigns – it is true and quite right that we should be wary of driving after even just one drink.  But this isn’t just about the dangers of intoxication; people think of the glass of wine after work in much the same way – only positively.

As I argue elsewhere (or at least try to, in articles under review), the idea of the carnivalesque is crucial for government, drinkers and the industry in distinguishing between different types of drinking.  However, underlying all these forms of drinking is the idea that alcohol is an intoxicant.

This might seem uncontroversial, and the sign of good alcohol education.  Organisations like Transform are always trying to highlight this, and I’ve done the same when T in the Park  supposedly banned ‘legal highs’ – except for the fact that it’s sponsored by the biggest of them all.

But such a view has a tendency to take the ‘drug’ out of context, and imagine intoxication as a pure process, when in fact drunkenness, at least, understood as a form of behaviour, isn’t this.  In contrast, it’s this distinction that is at the heart of the carnivalesque – it’s about something more than pharmacology; it’s about norms and culture.

And it’s here that the carnivalesque comes into its own.  My working theory is that, even if not everyone’s drinking in a carnivalesque way, now more than ever alcohol is associated with the carnivalesque, since our idea of intoxication is so imbued with this.  The lunchtime pint is, at some level, not seen as qualitatively different from the Friday night blow out.  The glass of wine after work doesn’t simply signify a ‘keying’ of a change in time; it’s also seen as a ‘release’ from the everyday – which is at the same time something more than pharmacological.

There are advantages to this, to be sure, but it’s also worth pondering the point that while the lunchtime pint and the Chancellor’s whisky became unacceptable, we all started drinking a bit more.

Alcohol might be more available and more visible than it used to be, and people might drink it every day, but it’s still far from ‘everyday’.  It doesn’t seem to be just another ‘ordinary commodity’ to the British public.

*For more detail about the carnivalesque, you could read one of my articles, but basically I mean drinking that’s public, exuberant, with different norms to everyday life.

Kidults and the old school beer

Phil Mellows yesterday pointed out one of the latest Portman Group judgements, which had to decide whether the names and labels of various beers were in breach of the code.  The names were: Cat Piss; Dog Piss, Bullshit; Dandelion & Birdshit; Big Cock; Grumpy Git; Arse Liquor; Lazy Sod; Puke; Shitfaced; Yellow Snow; and Knobhead.

I could just leave you with the link to the judgement (which also shows the labels), and allow you to giggle – or snort, as Phil did.

However, one bit of wording in the judgement caught my eye, given the one-trick-pony nature of my academic work at the moment.

“The Panel was concerned, however, that frequent references to scatological humour, defecation, urination, genitalia, vomiting and other bodily functions could prove particularly attractive to under-18s.”

If you added violence to this, it’s basically a description of the carnivalesque, which characterises Rabelais’ work, which is then drawn on by Bakhtin, and in turn drawn on by people like me (or this research team) to describe current town centre drinking.  (Flippant, but I don’t see young people eagerly reading Rabelais…)

I don’t want this post to turn into a detailed discussion of the codes used by the Portman Group and Advertising Standards Agency in relation to alcohol, but after reading this I started to flick through other recent judgements.

Perhaps unsurprisingly, a common feature of these is the feeling that products are appealing to children.  This isn’t just in a simple way, such that bright colours or fruit flavours are condemned.  A school has been condemned for brewing a beer to commemorate its 100^th anniversary – since there was then an unavoidable association between alcohol and the education of children.  Most bizarrely, the judgement stated: “while acknowledging that the school had taken steps to conceal the product from the pupils during school hours, it could not control children seeing the product if it was taken home by a parent.”

To me, this highlights the inconsistency of the Portman Group approach.  Public Health advocates complain that advertising and licensing ‘normalise’ alcohol consumption, and worry about alcohol being available in locations they feel it’s unusual and unnecessary, like cinemas.  It’s exactly this sort of worry that lies behind the condemnation of associating a school with beer – and yet the Portman Group represents manufacturers who do precisely this, and would argue that normalising isn’t a problem – alcohol is perfectly normal, but should be drunk ‘responsibly’; it’s only the errant individuals that need to be targeted.*

Obviously this isn’t an original or particularly interesting thought.  The strange role of the Portman Group is acknowledged by both (self-defined) ‘sides’ of the alcohol policy debate.  I just found the condemnation of a celebratory beer very strange – particularly when it’s an industry-related body doing the condemning.

The more general theme of complaints to the Portman Group  – as in the case of ‘Cat Piss’ beer – is that the drinks themselves would be appealing to children.  However, this is a line that is increasingly hard to draw, when UK drinking culture is carnivalesque (with the world turned upside down you can leave responsible adulthood behind) and where ‘kidult’ themes are common.

The suggestion is made in one complaint that a WKD ‘cauldron’ is irresponsible because:

“Halloween is widely recognised as a children focused evening, in particular with dressing up and trick or treating. The presentation of this product alongside the promotional posters, table talkers and mobiles would resonate with U18’s and make the product attractive towards them.”

But this isn’t simply about the evil alcohol industry appealing to kids. 

This distinction is hard to draw.  Is childhood the first thing young adults think of in terms of Halloween?  Possibly not; it’s probably now dressing up and parties.  There it is again – the kidult theme.

As we are in a culture where lots of the things adults are attracted to are child-like, the assumption behind this is that we need to encourage a culture that is sensible, staid and certainly sober.  I’m not sure I want to live in that world.  There are all sorts of problems with kidult themes – not least the way it potentially works both ways, with children wanting to be adults as well as adults wanting to be children – but to see it as a problem when alcohol simply reflects the society we already live in seems like backwards logic to me.

It’s noticeable that the Portman Group rejected the claim that the WKD cauldron was appealing to children (though it noted that alcohol content of any drinks in it would be unclear) while the school anniversary beer was condemned.  I’m not sure which way I’d have preferred the decision to go.  Maybe the answer is that neither should be condemned, and alcohol shouldn’t be seen as the carrier of all moral value.  Just something to think about.

*To be fair, the report linked to here isn’t an industry report, but it’s a good expression of the philosophy behind the approach that opposes population-wide interventions (like minimum unit pricing) in favour of targeted measures.

The proportionate universalism of MUP

In the past few days I’ve been catching up with videos from two conferences earlier in the year I wasn’t able to go to – those of Alcohol Research UK (ARUK) and the New Directions in the Study of Alcohol Group (NDSAG).

One that particularly got me thinking was John Holmes at NDSAG talking about minimum unit pricing (MUP) and whether it can be considered an equitable intervention that helps address health inequalities.  I’ve written about the Sheffield research and the predicted effects of MUP on different socio-economic groups before, but this time I started to think more directly about alternative policies.

As far as I can work out, there are two key reasons why MUP is considered a superior policy measure to increasing tax on alcohol across the board.

(One key argument against MUP is that any increase in revenue would be for the industry rather than the government.  It’s the same worry that some people have raised regarding initiatives to make food production healthier.)

The first is that it wouldn’t affect the on-trade, like pubs and bars, as prices there are almost always already above the 45p/50p per unit proposed – usually by some distance.  This is considered a good thing, because of the community value of pubs, and the fact that drinking under some form of supervision (by the licensee or social norms) is generally considered safer, and possibly a better way for young people to learn ‘how’ to drink.

The second, and what I’m interested in here, is that MUP wouldn’t affect all drinkers – or at least not equally or significantly.  Although it might seem like a population-wide measure in one sense, MUP wouldn’t affect everyone – or even all drinkers – equally.

Nick Sheron has suggested that MUP is ‘exquisitely targeted’ at the most problematic drinkers, but actually it’s more complicated than that.  As the graph from the Sheffield research shows, when we look at harmful drinkers, those from the lowest income quintile get twice as much of their units from sub-MUP level drinks (40.6%) than the highest quintile (20.3%).  So this is a policy that will affect those on lower incomes more.

Of course, if what we’re concerned with is alcohol consumption, then taxes on alcohol are already ‘exquisitely targeted’ – in fact, better than MUP.  Those who consume the most alcohol will pay the most tax, regardless of their income bracket or their preferred drink.  This would especially be the case if we had a more straightforward system than currently, and just taxed each unit of alcohol at the same rate (as the IFS has recommended) – though for reasons I can’t fully understand, this isn’t currently possible under EU regulations.  (True, these taxes would also affect on-trade alcohol, but then there are other ways to make that industry more viable if that’s a genuine concern of policymakers.)

However, this brings us back to the question (implicit till now but almost inevitable in a post on this blog): what is the policy trying to deal with?  Alcohol consumption, I’m going to assume, is not an evil in itself.  The reason that public health policies aim to address it is that there are risks associated with certain levels of consumption.  Those risks relate to mortality and morbidity of various kinds.  So what MUP would (or should?) be trying to do is reduce health harm related to alcohol.

Those harms are not distributed evenly across the population, and in fact aren’t even neatly related to levels of alcohol consumption.  Mark Bellis and his team are currently researching why it is that even controlling for levels of (reported) alcohol consumption, it’s those from the lower socio-economic groups that suffer the highest levels of alcohol-related health harm.

This means that, as John Holmes points out, the particular targeting of MUP needn’t be seen as a bad thing.  He calls this as a form of ‘proportionate universalism’, using the term coined by Michael Marmot, the doyen of health inequalities research.  It can be argued that the targeting only makes MUP a ‘regressive’ policy if the health effects of alcohol consumption are ignored.  If the assumption is that the aim of the policy is to improve health, the group with the most significant health harms from alcohol are the lowest quintile, and it’s their consumption that will be most affected by MUP – and therefore hopefully their health will improve most significantly.  That’s the proportionate universalism.

However, it could also be seen as a form of ‘seduction and repression’ to target those from lower socio-economic groups, who are assumed to be the ‘problem’ – as in David Cameron’s ’20 tins of Stella for a fiver’ claim.  (I’ve got an academic article coming out on this very topic in October – a mere 12 months after it was accepted for publication.)

If we’re trying to deal with alcohol consumption per se, then we know tax is a more straightforward and ‘equitable’ way to do this.  If we’re trying to address health harms amongst the poorest in society – and remember this is the only way that MUP can be justified as equitable – we know that even where these harms are apparently related to alcohol, there’s something more going on that we don’t yet understand.  In this context, pinning our hope on MUP when we don’t even understand what’s going on seems a bit premature.

MUP might be, for some people, the best policy available, and perhaps that explains why it seems to have been the only show in town in terms of alcohol policy over the past 5 years.  However, I can’t help but think sometimes that it seems to be a solution searching for a problem – and a whole range of people see it as a solution to the problem they’re most concerned with: ‘binge’ drinking, ‘harmful’ home drinking, health inequalities, and so on.

As usual, I’m not arguing that we shouldn’t introduce MUP, but if it’s really an intervention to address health inequalities, perhaps we should return to Michael Marmot’s analysis and think about the broader ‘determinants of health’ – and not just make alcohol more expensive for a specific group within society, who already have little income to spare.  Otherwise, it looks a bit too much like this is a policy that ‘targets’ those of the heaviest drinkers who have the lowest incomes, even if this targeting might also ‘benefit’ them.

Neoliberalism again

A long time ago now, I wrote an academic article about how alcohol policy under both Labour and the Coalition can be characterised as neoliberal.  The current advice for people who publish in academic journals is to get the ideas out to the widest audience possible using a variety of means.  I of course tweeted about the article, and emailed it to a few people who asked, and this blog post is a further attempt at getting the message out.

One of the things that I knew would happen, but still bizarrely surprised me when it inevitably did, was that after the initial publication, the world kept turning, government policy didn’t change, and not very many people even noticed I’d published anything.  Maybe writing this will go some way to making me feel a bit better about that.  More people are likely to read this blog than the article, at any rate.

The point of the analysis was to challenge the assumptions of some academics and public health professionals that alcohol policy has betrayed a certain ‘hypocrisy’ since the 2003 Licensing Act, or even before, with the market gradually becoming less regulated but the concern around alcohol – and ‘binge’ drinking specifically – increasing.  How can the government complain if people respond in the predictable way when an environment is established that makes them feel they have been ‘invited to binge’?*  This is the argument of the research group I think of as beginning with Hs: Hall, Hadfield, Hobbs, Hayward (and Winlow and Lister).

My response – this obviously fantastic article that you should download here (I can send a limited number of free electronic copies if you email) – is that in fact this is all perfectly consistent when considered as part of a ‘mentality of government’ called neoliberalism.  I’ve written about neoliberalism before, but I thought it worth thinking it through again given that some people I’ve spoken to about it haven’t really followed what I mean.

Unfortunately, neoliberalism isn’t a very clear term (in that sense, it’s got a certain affinity with ‘binge’ drinking already).  Mostly, people associate it with a slightly fuzzy idea that global banking and big business have been allowed to run riot over the past 20-30 years.  It’s got its origins in genuine political philosophy and economics as a policy framework, endorsed by people like Hayek.

However, that’s not quite how I’m using it.  In the context of social policy, it’s developed a slightly different meaning, as it’s used to apply to detailed analysis of how public policy has operated in practice, not as a theoretical ideal.  The key point is that recent social policy has not been liberal in the sense of genuinely believing that (for most people) an individual’s way of ordering their own life is by definition the best, since they will know their own desires and dislikes – and yet the solutions put in place to the perceived problems have tended to operate at the level of the individual (education, building resilience) rather than reshaping structures and environments (the ‘free’ markets are left as they are even when they are acknowledged to be producing undesirable outcomes).

I’ve suggested that UK alcohol policy (since 1997 at least) is a classic case of this approach.  While the Beer Orders were (at least by the Monopolies and Mergers Commission) justified as getting a fairer deal for consumers, the 2003 Act was justified for a myriad of reasons, but never as fostering the unconditional good that people should be able to drink when they want.  That was a conditional right: you had to drink in a particular way to be considered to be exercising this right ‘responsibly’.

This condemnation wasn’t only related to cases where genuine crimes were committed; government was swift to condemn ‘binge’ drinking even where there was no real harm (apart from offence) done to anyone apart from the drinker.  In fact, the harm even then seemed to be understood as shame more than anything else – the 2008 ‘Would You?’ campaign seems more like a lesson in how to behave as a respectable member of society than how to drink without engaging in crime and disorder.  (I'm not certain that the state should be too concerned about whether I've ripped my jacket or broken my CD player.)

The current government has suggested (wrongly, I’d argue) that the 2003 Act and other bits of Labour policy have produced serious problems.  However, the solution of the Coalition has not been to significantly change that environment, but to keep it broadly the same.  We haven’t actually had minimum unit pricing, and despite a consultation about ‘Rebalancing the Licensing Act’ the most notable changes mooted were actually to make it easier to sell alcohol, by loosening regulation of ‘ancillary’ sales (e.g. at hairdressers) and getting rid of the personal licence – something I’d suggest suits big companies most of all, which are precisely the organisations that commentators generally worry have made the night-time high street an unhealthy drinking environment.

You may or may not agree with this analysis (though I’d recommend you read the article in full first, before criticising!) – but I hope my motivation for writing it will seem reasonable.  I’m not necessarily convinced that all the things government worries about regarding alcohol are genuine problems, or that the state specifically should be addressing them.  However, given it has these concerns and makes policy based on them, we should have a sensible approach to devising solutions.  With the article I wanted to highlight the assumptions behind policymaking that mean the solutions proposed to the perceived ‘problems’ surrounding alcohol are (unnecessarily) limited.  That is, even though the outcomes produced under the current set-up aren’t what the government wants, it only really looks at solutions that address individuals.  I think we’d make better policy if we opened up the whole range of options that have existed through history.  In the article I mention the Central Control Board, as always, but that’s just by way of example; there’s all sorts of initiatives that could be on the table, but currently aren’t.

I’d like to think that the article and this post can contribute in a small way to opening up that debate.  And readers could always contribute by leaving a comment mentioning your favourite policy ideas that don’t currently get an airing…

*It's possible to argue that this idea that things have got worse as a result of looser licensing is misleading, but it's certainly the way that the current government portrayed the situation in the 2012 Alcohol Strategy.  This is partly possible to argue in the face of declining alcohol consumption because successive governments have defined 'binge' drinking simply as the sort of drinking they don't like, with norms different from everyday life, rather than based on quantity consumed alone.

A middle ground on drug policy?

Last week, I was invited onto BBC Radio Solent to talk to Simon Jupp about cannabis scratch and sniff cards – designed to educate the public about the smell of cannabis being cultivated, and therefore make them more likely to spot and report cannabis farms to the police.

Because I have a streak of vanity and egotism, you can listen to the brief excerpt below.  The only positive, really, is that I managed to get in my usual caveat when asked whether the scheme would work: well, of course that depends what you’re trying to achieve…  I tried to point out that, in itself, spotting and reporting an individual house being used to grow cannabis isn’t going to do much to address the key issues that surround illicit drug use in Britain today.

However, this interview isn’t something to boast about – it’s certainly not my finest hour, as I haven’t actually seen and played with one of these cards, and I don’t know how effective they’re likely to be.

Also, the discussion didn’t quite go the way I was expecting.  I had thought, given that this was on the day when Russell Brand and others were demonstrating next to Parliament, that we’d quickly progress onto broader issues of drug control, and so I’d had a bit of a think about that, and noted how many US states have legalised marijuana for medical and/or recreational use.

I’d made some quick, simple notes, therefore, about the arguments about drug regulation/legalisation.  I’ve been thinking about these this week too, having seen an article by Kathy Gyngell on The Conservative Woman blog, and something in The Economist about how decriminalisation should only be seen as a step on the way to the rational policy on drugs: regulated legalisation.

This is my attempt at what I said in a recent post academics should do: not just offering a critique of current policy, but suggesting a constructive alternative.

Of course, in terms of drug policy we can take the sensible position of the Irishman in the old joke: I wouldn’t start from here.  However, as Virginia Berridge points out so powerfully, simply thinking in the abstract doesn’t automatically generate sensible, workable policy.  We do need to start from here.

(At the same time, it’s worth understanding where we are, and this recent paper from the International Drug Policy Consortium highlights how the fact that some ‘drugs’ are legal and some illegal in the UK today is something of a historical accident.)

The crucial starting point is my old issue (and I make no apologies for sounding like a broken record): what are we trying to achieve with drug/alcohol policy?  Kathy Gyngell’s article focuses on individual users, and the risks they might face.

Some of these aren’t as clear-cut as she suggests – for example, the issues with the current criminal market doesn’t simply apply to drug possession offences, and the prison population doesn’t represent all those engaged with the criminal justice system, especially not for drug-related offences, where a Drug Rehabilitation Requirement (DRR) will often be a more appropriate solution.

Moreover, she presents the links between mental health and cannabis use as clear-cut, when they are anything but.  Just last week research was published that suggested both cannabis use and schizophrenia seem to be associated with a particular gene.  That is, the same genetic trait that fosters cannabis use might also predispose a person to have schizophrenia – and this might explain why they’re clustered, rather than a simple one-way linear relationship.

However, these individual arguments aren’t the only issue around there being a criminal market in drugs.  As I say in the interview, there are links with organised crime.  But this isn’t just about the example of trafficking that I managed to give in the interview; it’s also about the general instability of producer nations – as the Economist article notes.

This is in fact, for me, one of the most concerning points most about the current situation – and is likely to be how some of the greatest harm occurs.  However drug markets are controlled or regulated, there are likely to be ‘addicts’ of some kind – people currently benefit from treatment for issues with the legal drugs tobacco and alcohol as well as heroin.  An argument might be made that there are more heavy drinkers than illicit drug users in the UK, but that doesn’t necessarily imply greater health and crime costs.  I’m yet to be convinced that a cost-benefit analysis that looked at the global situation would conclude that greater damage is done by alcohol than drugs, if the way in which the illicit trade destabilises whole nations was taken into account.

One of the odd patterns in current drug policy is how greater regulation of tobacco is occurring at the same time as liberalisation of cannabis.  Admittedly, this is taking a global view, but as US states legalise cannabis – even for recreational consumption – Australia has introduced plain packaging for tobacco, and Britain is seriously considering this.

However, this doesn’t seem to strange if we take the perspective of Transform, an organisation that campaigns for liberal drugs policy.  It argues that there’s a U-shaped curve when harm is modelled against level of regulation.

That is, a completely free market in drugs would lead to high levels of harm – but so does attempted complete prohibition.  According to this interpretation, therefore, the most appropriate solution is a strongly regulated but legal market – somewhere in the middle.  Perhaps this approach appeals to me simply because of my tendency to see both sides of an argument, but it’s certainly worth thinking about.

What’s more, the current global trend suggests that this might be the direction we’re heading in anyway: both plain packaging and legalisation of cannabis for recreational use could be argued to sit somewhere in the middle of this graph.

There are arguments about whether highly regulated legality – through the Central Control Board for alcohol, for example – amounts to a middle ground.  Some see them as interfering with the market so much that they’re approaching prohibition.  This isn’t how I see them, however.  For illicit drugs, from the position we’re at currently, there would have to be decriminalisation before we even approached this level of controlled legality.  Licensed consumption locations for products that are quite clearly not ‘ordinary commodities’ seems perfectly sensible, and it’s also perfectly reasonable to imagine that certain conditions might be laid down in how those properties are arranged and run.

This trend isn’t necessarily the result of conscious planning – and my experience of policymaking is that these sorts of trends are more complicated than that.  We might be stumbling towards this policy mix thanks to an accidental ‘synthesis’ resulting from a whole range of groups including public health or tobacco control lobbyists as well as campaigners for drug legalisation.  This is precisely my view of how policy should be made.

So maybe there’s reasons to be cheerful after all, despite the shortcomings of scratch and sniff cards and Kathy Gyngell.