On the merits of blanket bans

This morning there have been two reports released by the Home Office: one on ‘legal highs’ and one on broader ideas of drug regulation.  I was asked to comment on these by Radio Solent, and I thought I’d post some quick thoughts here.  (At the time of writing, the full reports weren't available; only an embargoed press release with some quotes that I'd been sent.)

This isn’t a comprehensive response, but it did get me thinking about drug regulation more generally – a topic I’ve touched on before here and here, for example.  You can listen to one of the interviews in full here (with me starting at 2mins 50secs).

What’s being proposed is some form of blanket ban on ‘legal highs’, as opposed to the reactive banning done at the moment, through Temporary Class Drug Orders, and then adding substances to the list within the Misuse of Drugs Act.

The first advantage of this sort of blanket ban would be consistency with other substances.  At the moment, problems emerge by virtue of the special status unwittingly granted to ‘new’ substances.  People may be tempted to choose these over more established substances, which isn’t a great idea because everyone – from users to medical professionals – knows less about them compared to more established drugs.  Also, and this is something that was put to me by an interviewer yesterday, the apparently ‘legal’ status might be introducing certain people to drug use who wouldn’t otherwise consider it.

This second point isn’t necessarily a problem, unless that drug use is seen as dangerous and/or immoral.  However, that brings us back to the first point, which is that on balance I’d rather people were using cannabis than ‘synthetic’ cannabis, for example.  The advantage of a blanket ban is that, setting aside the detail, it sends the message that these substances aren’t endorsed or legal – and that’s one of the key potential problems with the current inconsistency: even where these substances are now illegal, they’re still marketed of and thought of as ‘legal’, and therefore (I’d suggest) at some level safe and endorsed.

Of course, the reality of the policy may prove problematic: will the government really be able to enforce a ban, and how will that affect research into new drugs and chemicals?  (Although the government has said before that controlling substances doesn’t inhibit research, I’m sure David Nutt would have a different view.)

We can predict pretty confidently that in reality, the government won’t be able to enforce a ban any more than it’s already able to enforce bans on use of heroin, cocaine, cannabis and any other illicit substances – particularly with the emergence of the ‘Dark Net’.

And here’s where the other report comes in.  That’s a review of evidence on how national drug policies relate to levels of use and harm.  That is, whether decriminalising use on the one hand, or introducing harsh penalties on the other, can change a country’s levels of drug use by.  From my sight of the press release scan, it looks like there isn’t really much in it: the harms depend on other factors.  As the report puts it: “We did not in our fact-finding observe any obvious relationship between the toughness of a country’s enforcement against drug possession, and levels of drug use in that country” (p.47).

In some ways, this is an argument for a sort of natural conservatism: why change the regulations, given that they’re irrelevant.  (This is interestingly not the minister’s take.)

I’m actually more interested in what the publication of the report says about the possibility of mature policy debate in this country.  Drugs policy is an area where thinking is not clear – or at least not generally conveyed clearly in public debates.  The report itself falls into this trap, solemnly declaring that we should have policy based on ‘evidence’ and talking in favourable terms of treating drug misuse as a health problem rather than a criminal one.

But these sorts of statements are close to meaningless in themselves.  As long as these drugs remain illegal, drug policy will always be a criminal as well as a health matter – and much of the criminal issues relating to substance wouldn’t be affected by decriminalising possession: if you still need to steal to feed your habit, I can’t see how that’s going to change by decriminalising the act of possession.

And evidence – as I’ve said before – doesn’t tell you what policy to implement.  That’s based on moral and political principles, and will be the result of a trade-off.

The advantage of this report, and the debate today in Parliament, is that they might actually open up some genuine debate about those aims and principles.  When Norman Baker says that policy should be based on evidence, this isn’t quite the right phrase – but there is definitely wrong with policy debates around drugs.  I think ‘legal highs’ (and e-cigarettes) could be the most important and interesting things to come along in recent years to promote an open debate that really gets to the root of what government should be interested in when it comes to psychoactive substances.

As Virginia Berridge points out, there are bound to be historical accidents and anomalies that shape approaches to different substances, but at the same time it would be nice to feel that there is conscious deliberation going on and to have some open debate about what makes alcohol, tobacco, coffee and all the rest different from ketamine, marijuana, heroin and all those other substances that the government has declared to be unacceptable.

So far, the conversation has only been about decriminalisation, and that’s where advocates of a more liberal policy would have to make a choice: is this a sensible first step in the right direction, or does it endorse what is fundamentally an unjust and unworkable system?  (You can see Steve Rolles and Julian Buchanan go over this ground pretty much every day on Twitter.)

Of course, one thing we often forget in these debates – and I haven’t touched on yet here – is how harms from drugs don’t only relate to users, but also producers and distributors of drugs.  That is, one of the biggest problems of making the drugs trade illegal is not the users in the UK, so much as the lives of those in producing countries, where crime undermines the state (think Mexico or Afghanistan), or those involved in production in the UK, who are often victims of trafficking.  It’s a great shame when this is ignored in favour of a somewhat parochial debate about UK heroin or cocaine users.

However, it’s not often I feel optimistic about policy – but today I’d rather focus on the positive (if only to distract from my tiredness at having got up stupidly early).  If a government can raise these issues shortly before an election, then surely there is hope that we can have that grown up debate, which would be a good thing regardless of your views on drug use.

Medication and Recovery - Magic Pills and Methadone

This week there’s been a lot of media fanfare around the ‘magic pill’ that’s going to save thousands of ‘mild alcoholics’.  I’m not usually in favour of putting things in quotation marks, but in this case it’s almost obligatory because the fanfare is quite clearly over the top.

I don’t particularly want to write about the weaknesses of this approach; that’s been done very well by Niamh Fitzgerald and Matt Field here.  Also, although it’s tempting, I don’t want to analyse all the misunderstandings behind articles such as this by Hugh Muir in the Guardian.

What I am interested in is what the fervour says about how public debate around alcohol and drug use is able to sustain apparent contradictions in understanding different substances.

For the past few years – at least five – the field of drug treatment in the UK has been grappling with the issues of ‘medication’ and ‘recovery’.  What does it mean to ‘recover’ from a ‘substance misuse disorder’ (and what is one of these anyway?) and what role can and should medications like methadone play in that process?

This is the point of the much referenced Strang Report, called, in fact, ‘Medications in Recovery’.  (Though as I said to someone who sat on the panel – though I didn’t know at the time – that was all a bit of a fudge anyway, since although we can all agree that ‘recovery’ is a good thing, the word itself only begs all the crucial questions that still need answers.)

Anyway, the upshot of this great debate is an increased emphasis on the importance of psychosocial interventions – or ‘talking therapies’ as they’re more commonly known – in fostering recovery, and a concern that long-term medication doesn’t really amount to ‘full recovery’.

To add to this feeling of moving away from medication, the trends in drug use – and therefore need for treatment – suggest that fewer people are using opiates like heroin, and there’s an increase the relative importance of drugs like ‘legal highs’ (or ‘new psychoactive substances’) that don’t fit a model of substitute prescribing in the model of methadone for heroin – in fact they often don’t fit any model of prescribing at all.

I’m not saying the shift in emphasis away from methadone maintenance is right or wrong – or that the way this has played out is the same everywhere – but the key point is there’s been a crucial shift in emphasis in public policy debate.

This shift actually ties in quite neatly with broader trends in medical policy so emphasise ‘social prescribing’ rather than imagining medicines can sort everything.  Of course this opens up a can of worms as to whether it’s fair to characterise GPs as ‘pill pushers’, but this is a definite direction of travel in primary care policy discussions, only amplified by current concerns around antibiotic resistance.

You might even make links to broader public policy trends.  Methadone maintenance works on the principle that if you get rid of physical cravings for a drug, someone won’t need it, and therefore should be well-placed to stop using it.  But behavioural economics – which underpins the popular ‘nudge’ theory of public policy – reminds us that we don’t necessarily act on the basis of what we ‘need’ or what’s ‘good’ for us.

It’s in the context of this mood of public debate that Luncbeck has emerged with Nalmefene – or Selincro, as it’s marketed.

It’s worth noting at this point that Nalmefene is actually an opioid antagonist, similar to Naltrexone, which is used to treat heroin users.  That is, it blocks the receptors that give opiates like heroin their pleasurable effects on the body.  It’s precisely this sort of intervention that opiate treatment in Britain is (arguably) moving away from.

One explanation for the fanfare, then, is simple business logic: pharmaceutical companies see an opportunity in the public concern about (non-dependent) drinkers, and so manufacture a relevant product, which fits particularly well with the fact that the UK market for opioid agonists and antagonists is likely to shrink in the coming years.  A ‘pill’ that’s similar to what’s been used for opiate treatment can now be used for alcohol treatment, just at the point when the general feeling is that alcohol treatment services need to be expanded (probably at the expense of drug services designed for heroin users).

I think there’s something more to it than that, though.  This isn’t just about Lundbeck putting out a press release and there being a slow news day.  Nalmefene is genuinely more likely to find favour than similar drugs designed for people with issues with substances other than alcohol.

I think the fact we’re so interested in this ‘magic pill’ at the same time as think tanks as varied as Demos and the Centre for Social Justice talk about the importance of ‘character’ and how drug users ‘have a responsibility to work towards their own recovery’ to take ‘responsibility’ for their own recovery, and the Conservative Party announces the idea of ‘benefits cards’ for those with substance misuse issues, points to a distinction made between alcohol and other drugs.

This distinction is also infused with a notion of class – as the idea of benefit cards makes clear.  It might be worth asking whether – if the aim of these cards is to protect families from the impact of parents diverting resources ‘to feed their destructive habits’ – the same protection should be afforded those in families not receiving benefits.

Regardless of this policy question, though, there is a difference in who is expected to show self-reliance and not be medicated by the state, and who we think might benefit from the ‘magic pill’.  The latter are drinking half a bottle of wine a night, apparently – and the very choice of drink to illustrate the problem says something about the way it is understood.

If we think back to the idea that the shift away from methadone maintenance might dovetail with the principles of behavioural economics, in fact the opposite could be true: you could argue that a pill to deal with cravings fits perfectly with the idea that we’re weak-willed, irrational beings – we can’t be trusted to moderate our drinking simply through reason and self-control, so we need a pill to do it for us.

The question is: who gets a magic pill and who has to demonstrate self-reliance?  I’m not sure the answer doesn’t depend on the substance being used and the status of the user.

Drinking within limits with Drinkaware

Last week, Drinkaware published a report called ‘Drunken Nights Out’.  It’s definitely worth reading, and the analysis of drinking practices and beliefs underlying it is surprisingly nuanced and thought-through.  Perhaps that’s testimony not only to the researchers but to those who sat on advisory panels.  If you don’t have time to look through even just the executive summary, then I can recommend a summary provided by Alcohol Policy UK.

The report carefully assesses people’s beliefs, behaviours, activities, fears and motivations.  For example, it’s noted how (certain forms of) drunkenness are considered normal, that many people’s early experiences of drinking enforced an instrumental approach to alcohol (drinking to get drunk), but that even such determined drunkenness (as Measham and Brain would call it) is ‘within limits’.

It’s this last point that’s particularly interesting, because it’s noted that these ‘limits’ aren’t like the limits government refers to, and in fact are framed in completely different terms.

However, the report falls down, in my opinion, when it moves to solutions to the perceived problems.  This is partly due to the restrictions applied to the scope of the report, but it’s also due to certain assumptions applied.

First, the report sets its terms of reference by stating that it’s only concerned with what’s in Drinkaware’s remit.  In the eyes of some public health professionals, this will immediately limit its usefulness, as the key factors of price and availability are not within Drinkaware’s gift.  Moreover, it’s stated that the report takes a harm reduction approach, meaning that it’s not aiming to reduce the number of ‘drunken nights out’ so much as reduce the harms associated with them.

This statement leaves me in a slightly uncomfortable place.  I agree that the focus shouldn’t particularly be on reducing the number of drunken nights out per se.  If people want to spend their evenings (and money) on this, I can’t immediately see why it’s any more execrable than partaking in state-subsidised opera, or skiing (so long as they know what they’re getting into).  Both of those alternatives often (or always in the case of certain opera companies) involve the state paying for the choices of individuals, which is the only real downfall of ‘drunken nights out’ as identified by Drinkaware.

On the other hand, that limiting of the scope of the report doesn’t actually follow from the initial statement that it will only look at interventions that are in the gift of Drinkaware.  In fact, given the strong links between drinking, drunkenness and the carnivalesque (or simply outrageous behaviour) in the way we think about alcohol in today’s Britain, it could be argued that educative approaches would be more likely to persuade people to go out on such nights less often, than to completely change their understanding of alcohol.

This brings me back to my old frustration with the alcohol industry (though I shouldn’t lump a whole range of interests together like that).  I often agree with them, but sometimes for completely different reasons, but other times find myself hugely disappointed by their cynical, self-interested approach – and I can’t help feeling this report is too constrained by a particular way of thinking about what is appropriate for Drinkaware to do.  I don’t think in this case these limitations are due to the same calculating cynical approach I’ve seen from the WSTA and Portman Group, but rather just accepting what they already do as inevitable restrictions.

But back to the practical recommendations of the report.  First, there’s one suggestion that people with a public health perspective should be applauding.  The report notes that education initiatives should challenge the assumption that if you ‘get away with it’ on the night, there’s no long-term problem.  Once the hangover is gone, you might feel fine on each occasion, but you could be doing long-term damage to your health.  I don’t expect to see a magical intervention that can successfully defeat this assumption, given that a belief in one’s immortality is something we cling to despite mountains of evidence – but this is an appropriate target for intervention.

After this, though, my academic perspective saw a couple of key flaws in the approach.  First off, methodologically, there are problems with simply asking people what they think or do regarding drinking.  We’re actually concerned with what they do, which doesn’t always correspond exactly with what they say – particularly regarding drinking within limits or having safekeeping strategies.  Most people know that some of the best laid plans for a night out can often fall apart in reality.  You have just one more drink, and raid the money you’ve saved for the taxi home to do this, but you might well still talk about knowing your limits and setting boundaries when you describe your drinking to other people.

This then leads into the broader point around limits.  Although the report is refreshingly clear about people having limits around their drinking, it doesn’t pay enough attention to its own acknowledgement that these are founded on completely different principles to the limits the government espouses, or indeed those placed on the same individuals’ behaviour at other times in the week.

I never seem to stop citing MacAndrew and Edgerton on drunkenness and limits, and here’s another opportunity.  Basically, they compared how drunk people behaved (and were treated) in different societies, and argued that drunkenness is set of norms and is ‘learned’ as much as everyday behaviour.  To give a simple example, in some societies people became fired up when drunk, whereas in others they chilled out.

And the ‘limits’ were different too.  Even when apparently blind drunk and on a drunken rampage, a reveller in one society found time to apologise to a researcher – acknowledging that his actions were ritualised and the outrage shouldn’t apply to a visitor.

These sorts of limits aren’t what Drinkaware is talking about in the report; they’re wider and more fundamental.  They are not about whether you set yourself the limit of four drinks or five on a works night out, but instead whether murder, drink driving or domestic violence when drunk is acceptable.

These sort of limits aren’t just individual; they’re influenced by broader issues like the legal framework surrounding alcohol.  That doesn’t mean Drinkaware can’t do anything about them, though.  And more importantly it has serious implications for the solutions proposed in this report.

The report makes the same mistake as the ‘Would You?’ campaign, which I’ve written and spoken about a number of times at conferences and in academic articles: it suggests that education campaigns should remind people that ‘they would not accept such behaviour outside the context of drunken nights out’ (p.10).

This is irrelevant.  The whole point of ‘drunken nights out’ is that these evenings operate under different norms to the everyday.  To tell someone they wouldn’t accept this behaviour outside of a drunken night out is just to remind them that’s why they go on these nights out in the first place.

I’d suggest that a more appropriate response is to stress certain absolute lines.  Looking at the work of MacAndrew and Edgerton, or indeed our experience in recent decades in the UK, we can see that certain things can be branded unacceptable regardless of drunkenness.  The claim shouldn’t be that you wouldn’t do something sober, making the comparison between the two scenarios; it should be simply to state that certain behaviours are unacceptable regardless of context.  We’re perfectly capable of holding onto certain norms when drunk, and there’s no reason to think this approach shouldn’t be considered within the scope of Drinkaware.

This might seem like a semantic distinction, but I think it’s crucial, and does reflect a genuine misunderstanding on the part of the report’s authors.  It’s not just that such strategies wouldn’t be effective; it’s also that it would be sad to apply everyday norms to all aspects of human life, and that’s what the general philosophy of ‘you wouldn’t do this sober’ suggests.  There are some benefits and pleasures in drunkenness and carnival.

What's new about neoliberalism?

A while ago I wrote about an academic article I’d had published that suggested successive governments’ alcohol policies can usefully be labelled neoliberal.  The reason this was worth saying, I suggested, was that some policy commentators have talked about policy entering a new phase since 2008, as confidence in market mechanisms and individual rationality have faltered in light of the crash and recession and there’s been an increasing emphasis on community-focused interventions through developments such as Blue Labour, Red Toryism, and David Cameron’s idea of the Big Society.

The first step in this argument is to note that governments have loosened regulation of the alcohol industry, particularly through the 2003 Licensing Act, but also well before that, from the 1980s on.  Phil Mellows has suggested that the Beer Orders can be seen as neoliberal, as (however misguidedly) they sought to open up the market to greater levels of competition.

But in itself this could just be liberalism.  The same arguments about competition were made in the nineteenth century in terms of the Beer Acts.  What made these more recent developments neoliberalism, I argued, was the peculiar way in which government was clearly panicked about alcohol and worried about particular types of drinking.  Alcohol strategies were published by successive governments, and millions of pounds were spent on advertising campaigns to persuade the public to Know Your Limits, know your Units, and behave on a night out in a sober fashion.

This can be seen as neoliberal because it isn’t based on a belief that a person’s own way of laying out their life is by definition the best for them.  Rather, the government thinks it knows best, and it’s unhappy about the results produced when British people (who are born to binge?) are invited to binge.

For most of the twentieth century, the response by government to such a feeling of unhappiness would have been to change the environment that seemed to produce that outcomes – hence the Central Control Board (CCB) and the retention of relatively restrictive licensing laws even after the end of the First World War, more or less through to the 21^st century.  It’s not really important what this period is called (some would question the term ‘expansive liberalism’ which a few social policy academics use), but it’s clearly quite different to the approach to alcohol policy taken by successive governments in the past 30 years.  In this more recent approach, the market is taken as given, and it’s the individual drinkers who are told to change.

It’s possible to say that the 20^th century was unusual in terms of the restrictions put on the alcohol trade, but I’d argue that such a position is misleading.  Retail of alcohol has been licensed for centuries, and it was only for rare periods of history that numbers of pubs, inns, taverns, alehouses and so forth were determined solely by market forces.  In fact, schemes comparable to the CCB were in operation in a range of towns at various points in the early modern period, on the basis that directly controlling the numbers of licences wasn’t enough; the profit motive should also be removed from licensees’ day-to-day operations.*

So far, so neoliberal.  And yet, writing recently about the particular context for England’s apparently neoliberal alcohol policy (it unsurprisingly involves the carnivalesque, in case you were wondering), I was reminded of James Nicholls’ work on liberalism and alcohol policy, and his broader work on the history of alcohol policy, which notes how many of the same arguments and dynamics crop up again and again – if in slightly different forms.  This reminded me that there isn’t a single ‘liberal’ position in relation to this unusual substance, alcohol.  TH Green was a liberal who advocated prohibition, while this was anathema to JS Mill.  Perhaps we could see the 20^th century as a form of watered down (or beered up?) TH Green style liberalism, and the current period as Millian?  (This post owes much to James Nicholls.)

The distinction between the period from 1915 to the 1980s and the time since then is, in my account, that both had clear view of how people should drink, and accepted the free(ish) market wouldn’t produce these, but the solutions to this perceived problem were different.  The first sought to change the environment in which people made their drinking decisions; the second sought to change the people.

The latter might sound distant from an idea of pure, classical liberalism that values individual judgement, but is in fact remarkably similar to the views of Adam Smith or Mill.  They accepted that there were higher pleasures, or that the desire for drunkenness was a bad thing – but argued that education, exposure to alternative pastimes and changes in working conditions would be better solutions than limiting the numbers of alehouses or prohibiting the sale of alcohol altogether.

Hasn’t that been the hope of Labour and Coalition policies?  Drop MUP but keep funding Units, Would You and Change for Life to show people the ‘better’ life they could have?

Maybe this neoliberalism isn’t so new after all.

*See the chapter by James Brown in this excellent book.

The old news of sobriety orders

Here’s my second post inspired by Keith Humphreys, this time covering the recent announcement of sobriety tags for certain alcohol-related offenders in London.  (It’s worth noting at this point that a similar scheme was introduced in Strathclyde some time ago, though that’s not mentioned in the mayoral press release.)

The rationale for the policy is explained clearly here, but its application to a wide range of offences initially made me feel uneasy.  In the US, from what I can tell, the schemes were run – in the first instance at least – to address drink driving offences.  Setting aside the thorny issue of fixing an exact ‘safe’ limit of alcohol, people are not allowed to ‘drink and drive’, and when they do the restriction has generally been of their driving rather than their drinking.

There’s actually no reason why this shouldn’t be reversed if it’s more effective.  It’s not necessarily true that these individuals are bad drivers when sober, just as they may hurt no-one when they drink unless they drive.  To fully forfeit one right is no more arbitrary than forfeiting the other, since the precise offence is the combination of drinking and driving, not either on its own.

The requirement to stay sober fits, though, because of the specific nature of the offence of drink driving: we have a specific, apparently ‘objective’ limit on blood alcohol concentration, over which a person is not allowed to drive.  Driving while ‘drunk’ is an offence in itself, banned on the basis that there is a direct physiological/pharmacological relationship between alcohol consumption and impaired driving.  Without the alcohol, there is, by definition, no drink driving.

We know this is not the case for violence and other crimes.  Not everyone in every culture is more likely to become violent or commit a crime when drunk; the way we behave when drunk is learned and more conscious than we might think (given that we react in similar ways when we’ve drunk a placebo).

Combined with the way the offences are defined, this means that we just can’t say for an individual who commits an offence while drunk – as we can for drink driving – that without the alcohol there is no offending (of this specific nature).

Of course the same sort of principle already underpins Drug Rehabilitation Requirements (DRRs) or Alcohol Treatment Requirements (ATRs), which are used as part of community sentences now, and which I’m very much in favour of.  These are handed out where the courts feel the offending is drug- or alcohol-related.  However, those should do far more than simply stopping an individual drinking; they should look at why they drink or use drugs and why they commit crime.

I agree with Keith Humphreys that people frequently recover from drug and alcohol use without accessing specialist services, and this new initiative offers them an incentive to kick start that process regardless of any related treatment requirement, but the relationship between drinking and offending more broadly isn’t quite so straightforward as drinking and driving.  It’s clear the scheme designers are aware of this, as they have excluded domestic violence offences from those listed as suitable for tagging.

I’m not against the scheme, but when it’s looked at in some detail – it will be supervised by probation and those on the programme will be offered alcohol advice and treatment – it’s apparent it’s not a huge innovation, but simply a technically more effective ATR, and almost identical to DRRs, which already involve drug testing.  To be fair to Humphreys, it’s the technical and procedural innovations he stresses, but it’s certainly far from the revolutionary or radical initiative some have painted it, whether in favour or opposed.

The key difference from DRRs is, of course, that those ‘drugs’ by that definition are illegal, and so it doesn’t seem so unreasonable to require someone not to be using a particular substance.  Although the argument of the Adam Smith Institute that the tags are a novel infringement of civil liberties falls down somewhat given that ATRs have been around for years, perhaps what’s really highlighted is this inconsistency: we really feel that it’s an Englishman’s right to drink beer.

And so we’re back to Virginia Berridge again: I wouldn’t start from here.  It’s maybe not helpful to have that feeling of a right to beer, if indeed that’s what’s going on.  Unfortunately, policy has to start from here.  A liberal argument can be made that action should be focused on the offences, not the alcohol, but the idea of limiting people’s access to certain factors that influence their offending behaviour if they tend to commit crime is pretty well established.  I’ll be interested to see not just the evaluation of the project, but whether whatever government is in power after next year’s election feels the scheme is something it should endorse nationally.

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.