Thinking beyond population harm and addiction

I often mention on this blog the range of problems that are associated with alcohol, and how this can muddy the waters when we try to discuss alcohol policy: are we worried about violence and antisocial behaviour linked to ‘binge’ drinking; health and social problems resulting from addiction or dependency; or the risk of health harm due to long-term use?

I was reminded of this yesterday for two reasons: a neat diagram I saw on Twitter from James Nicholls; and a conference I attended discussing the links between intimate partner violence and substance use, and how to address this.

James’ diagram showed a summary of how alcohol problems have been understood and the dominant policy approach taken by campaigners – for example, a belief in the 18^th century that spirits produced a new and dangerous type of drunkenness, and therefore that they should be specifically controlled (and perhaps beer consumption encouraged instead).

The example given for policy today was that campaigners have moved away from focusing on addiction as a disease (and therefore targeted treatment as a solution), towards a preference for understanding alcohol problems as being on a continuum, and the appropriate solutions as being focused on the supply of alcohol (e.g. price and availability).

The only problem with this way of thinking (and I’m not criticising James, just the public debate he’s analysing) is that if there’s a whole continuum of alcohol-related problems, it seems odd to focus on availability as the solution.

There is a strong argument that reducing availability affects use and therefore to some extent the scale of social problems associated with substances.  A key reason (though not the only one) why there aren’t that many heroin users in Britain, and there are far fewer heroin-related deaths than alcohol-related deaths is that it’s not as easily available.

(Of course heroin us isn’t as socially acceptable as alcohol use, but again the two things (availability and a culture of consumption) are linked: alcohol is available all over the place – and supported by politicians as an industry – because it’s socially acceptable, but it’s acceptable (or normal) partly because it’s so visible and available.)

But all that doesn’t mean that availability is the only game in town; it’s certainly not what most drug campaigners focus on.  Whether you have a relatively free market in substances, one that’s reasonably well-regulated, or one based around prohibition, you’ll still have people using substances who need some form of help to reduce the health and social harm caused by their use.  Current treatment services in the UK have plenty of users of both alcohol and heroin.

You can call that level of use ‘addiction’, or ‘dependency’, or ‘heavy use sustained over time’, or you might be thinking of ‘risky single occasion drinking’ – and all those might describe genuinely different patterns of use that imply a need for different sorts of support.

And that’s where the debate in the UK has fallen down.  There’s a tendency to leap to see either the substance (alcohol) as the problem, or identify particular people (alcoholics, drunks, or whatever label is in fashion) as having weaknesses or vulnerabilities to it.  In the 20^th century stage of James’ model, although it isn’t seen as a person’s moral failing, particular people are picked out as having a ‘disease’.

There’s always an issue around stigma, though, when you focus on individuals.  Kettil Bruun argued that focusing on populations was a neat way to get around this – and you could still implement interventions on this basis that were effective for those most in need of help.

Some current commentators on substance use (notably Johann Hari) have tried to bypass this debate by plonking down (without admitting it) the old sociological concept of ‘structure’ to replace the ‘agency’ of the individual who might have a problem.  That is, it’s suggested that the problem doesn’t reside in particular substances (and people often replace an ‘addiction’ to one substance with some other form of addiction – to activities like shopping, sex or gambling as much as substances).  Instead, with frequent reference to ‘rat park’, the wider social environment is seen as the problem: people who have issues with substances variously need ‘jobs, friends, houses’ or social ‘connection’.

In reality, this doesn’t get us out of the debate on whose ‘fault’ addiction is, as any sociologist who’s tried to write about structure and agency would be able to tell you.  (Don’t get me started on Anthony Giddens and ‘structuration’.)  The reality is bound to be more complex, where some people’s issues will be primarily down to their social environment, others a genetic predisposition, others simply to the risks inherent in alcohol consumption, where they didn’t particularly have any other warning signs.  Most are a combination of a whole range of factors.

And this formulation still leaves us focusing on a particular cohort of people: those who are (whether we use the word or not) ‘addicted’.  And even if you’re not saying that individual has a moral or genetic ‘failing’, there’s still something stigmatising about pointing out which group in society is in greatest need of jobs, friends and houses, and social connection – and there’s a danger this plays into certain damaging narratives around ‘sink estates’.  When you hammer home the importance of wider social structure, there’s not much ‘agency’ left to that individual to find meaning and stop feeling powerless in their own life.

But what’s this got to do with intimate partner violence (IPV) and yesterday’s conference?

Well, you can see the ‘jobs, friends, houses’ narrative as having just the same aim as Kettil Bruun’s population-wide approach: make sure resources are there for those who need them most.  Only in this case, it’s a response to the fact that the population-level approach seems to be shifting attention from those with the least ‘recovery capital’ to those with the most: brief interventions and universal efforts to reduce everyone’s consumption just a little bit.  By reminding us of the need to focus interventions on those who actually need jobs, friends, houses, we can target scarce resources most effectively.

(I should point out that this is only my speculation on the motives of some who’ve made these claims; probably not Johann Hari, who’s more concerned about stigma and a more liberal drugs policy.)

But as we talk about jobs, friends, houses (I know it’s getting tedious repeating that phrase) we’re really just talking about ‘addiction’ or ‘alcoholics’ in a new language.  We’re still focusing on one particular segment of a broader spectrum of problems.  And that poses a big problem for some of the possible responses to IPV that were discussed yesterday.

It was pointed out that while programmes to treat perpetrators of domestic abuse mostly run through criminal justice services, only a small proportion of those who commit these acts come into contact with the criminal justice system, and still less for these specific crimes, which is how people come to be referred to these programmes.  By contrast, a high proportion of those in substance misuse treatment admit to having committed IPV (though they wouldn’t necessarily see this as a crime, particularly where it doesn’t involve physical abuse).

This is the logic for hosting such programmes within substance misuse treatment services, or at least referring people through them.

And research with the partners of perpetrators that was presented at the conference by Ingrid Wilson suggests that alcohol is indeed closely related to IPV.  (And I have to say I thought her model of the stages of drinking and IPV was one of the best results of a grounded theory type approach that I’ve seen.)  But I’d suggest that the drinkers described by their victims had more in common with ‘binge’ drinkers – or perhaps those who engage in “frequent occasions of heavy drinking that [also] result in heavy volume drinking”.

And those are the people who don’t fit into that binary debate of population-wide or targeted measures, as long as we see the ‘target’ of treatment so narrowly.

If we really think there is a continuum of harm in relation to substances (and alcohol in particular), then we need to think of a full continuum of interventions.  And that means having more nuanced discussions than we do now.  Binary thinking might help frame some discussions, and will win some arguments, but it can’t give the full picture, or provide a complete answer.

In defence of alcohol guidelines

The last week or so has seen some pretty strong debate around the proposed alcohol guidelines published by the Chief Medical Officer.  I’d sort of assumed that, like many news events, this debate would be replaced by another issue after a day or so, but in fact a letters debate was still being printed in The Guardian on Thursday 14^th January – almost a week after the guidelines came out.

This debate, as I predicted when the guidelines were released, seems to have involved people talking past each other, often from ill-informed or inconsistent positions.  The letters to The Guardian are a case in point, so I want to spend some time here talking their criticisms through.

I should start by acknowledging my personal position in this, as I think this is important in how we react to guidelines.  I drink between 20 and 30 units most weeks – about 3 pints on each of Friday, Saturday, Sunday and Monday.  (For those of you who are wine drinkers, this works out at more than 2 or 3 bottles a week.)  I drank more than the ‘old’ guidelines, and I certainly drink more than the ‘new’ guidelines, as the threshold for men has been lowered.

I often feel torn on alcohol issues.  Thinking of a similar discussion about older people’s drinking, you could say I took a different position, challenging Jackie Ballard on her assertion that older people’s health would inevitably be damaged by increased levels of alcohol consumption.  The evidence we’d just been presented with flatly contradicted this point (which is a complete misunderstanding of the nature of risk and uncertainty).  There’s also a danger that if you tell people a certain level of consumption will definitely cause health damage they’ll switch as off, because they’ll probably know someone who drinks at that level and hasn’t suffered any harm.  That’s the nature of risk.

Equally, though, I’ve been quite supportive of the guidelines released this week, which have had exactly the same objections thrown at them.  I value having them even while I’m not exactly in step with their model of low-risk behaviour.

But I think this feeling of being unsure is appropriate – alcohol can be both pleasure and poison, even at the same time.  If we’re comfortable with a simple, coherent position, we’re probably missing something.

More than this, though, there is a difference between telling people what to do and giving them information.  It’s exactly why I welcome the advice, but don’t stick to the low-risk limits.

Jackie Ballard was wanting older people to drink less, and wanting to tell them so, based on what I saw as a misreading of the evidence.  This is exactly what the Chief Medical Officer and related researchers have been accused of in the past week or so, but in fact I’d suggest they’re doing something quite different.  They’re trying to offer information about risk to guide individual decisions.  (And this information only related to medical risk – so you may wish to balance it against the physical or social pleasures of drinking.)

14 units a week or less would be a good level for everyone to drink at from a public health perspective, considering overall population health outcomes like hospital admission rates, but it’s up to each individual to judge whether that sort of health improvement is of any interest to them.

There seems to be a school of thought that thinks because giving advice is difficult, we shouldn’t do it at all.  That is, each person has different genetic and environmental factors that will influence their level of risk, and so it’s impossible to give a single risk figure for all people in the population, making any single figure misleading.

But my response to this is that we use these single approaches in all sorts of elements of life.  We set a single age of criminal responsibility (apart from in exceptional cases), even though we know people’s maturity and powers of reasoning vary considerably.  We set a single speed limit even though different cars and drivers have different stopping distances.  In terms of health and lifestyles, we give single figures for recommended exercise or fruit and veg consumption.  I’m not saying these are all the right way to approach these issues, but the idea of a single target or recommendation is not unique to alcohol guidelines, or even unusual.  It’s a standard approach to advising and governing behaviour.

I would argue that if we’re making decisions that affect our health, it’s helpful to know the best information possible about how that might happen. 

This is why I think the letter written by Jack Winkler, Emeritus professor of nutrition policy, London Metropolitan University, is wrong when it complains that we need a more complex response, ‘not just admonitions’.

In fact, it could be seen as dishonest to provide medical professionals with tools by which to screen people for problematic alcohol consumption, and then not give drinkers themselves access to the same information.

One main argument – put forward by Sally Caswell previously and Chris Hackley more recently – seems to be that giving out limits puts the onus on the individual to manage their own risk, and distracts from lobbying from more effective controls on price, availability and so on.

As I’ve noted before – and did when these guidelines came out – there is a genuine concern that recent trends in government policy focus too much on individual decision-making, neglecting the wider context that shapes these decisions.  (This is what is generally meant by neo-liberalism in a social policy context.)  So I’m sympathetic to the idea that guidelines could distract from other elements of the alcohol policy picture.

However, I’d draw attention to Nick Heather’s response to this.  The simple answer is that if alcohol is legal and available in any form, individuals will be making decisions about how much to consume and in what format, pattern and setting.  These decisions unquestionably affect a person’s risk of health harm.  And there is, unavoidably, a certain sense of responsibility.  This is not simply ‘victim blaming’, but an awareness that we make our own decisions, though not always in circumstances of our own choosing (to badly paraphrase Marx).

Chris Hackley has responded by pointing out that the research is already out there, so why have (simplifying and misleading) guidelines?

But these letters to The Guardian show that even making the research available alongside the guidelines doesn’t mean it will be read and understood.

David Lewis from York writes that “The guidelines conveniently ignore the evidence around the cardioprotective and neuroprotective effects of moderate alcohol consumption.”  They absolutely don’t.  There’s careful discussion of this in the Sheffield model, and that’s part of why the guideline isn’t set at zero despite the fact that for many conditions there is no ‘safe’ level of consumption.

Dr John J Birtill from Guisborough in North Yorkshire states that the guidelines “tell us nothing about how much longer the non-drinkers will live on average, the range of this extra life expectancy, the quality of life during the extra years, or the likely alternative causes of death. The lifetime benefit of abstention might be rather small compared to the lifetime pleasure of moderate alcohol consumption.”

In themselves, perhaps they don’t; they’re just low-risk guidelines.  And any condensing leads to interpretation.  But the report they’re written into does talk about precisely these issues, and the Sheffield report gives even more detail.  These things aren’t being hidden; they’re part of the discussion.

And the whole point of Millian liberalism is that the individual is best placed to decide about their own ‘pleasure’ in various activities, so it would be odd if the state stepped in and said this is where the perfect equilibrium lies.  This correspondent seems to be objecting the fact that the state hasn’t done this, at the same time as complaining that effectively it has.  I’m confused.

Some of those writing in are clearly highly motivated to find out about this issue, and highly qualified, seeing as they’re listed as doctors and professors.  And yet they’ve failed to read (let alone understand) what’s already available and clearly signposted.  So what hope would the rest of us (most of whom aren’t actually that interested in the detail) have of finding out and understanding without providing these simple guidelines?

So I still can’t see what harm having guidelines does.  And if we’re having them, what’s so wrong about something that gives the level at which you’re taking the same risk as the average car driver?

Sure, they don’t deal with all the myriad problems alcohol can cause.  And they won’t be effective for everyone.  And they aren’t the only policy tool available.

But while alcohol is legal, isn’t guidance on risk something a consumer should reasonably expect to be given?  In fact, we even give this kind of guidance about ‘safer’ consumption levels/patterns/settings with illegal drugs: always use with other people; never share or re-use injecting equipment; smoke rather than injecting; reduce your dosage after a period of abstinence; and so on.  Maybe alcohol users deserve the same courtesy we grant users of other substances?

Still hoping for a balanced debate

As I never seem to tire of pointing out, there are a myriad of perceived problems related to alcohol, affecting different people, and caused by different combinations of a range of factors.

It shouldn’t be surprising, then, that whenever a policy or evidence discussion occurs – like today’s debate about guidelines for low-risk drinking – it’s almost inevitable a lot of people talk past each other.

(I, of course, would never do that, and if you want to hear me talking to, or with, or at [certainly not past] a BBC interviewer, you can listen here.)

I’ve written before about how the word ‘addiction’ can sometimes confuse as much as it explains, and yesterday dragged some very reasonable and knowledgeable people into an argument about whether there are the same problems with the idea of ‘dependent’ drinking.

So what are these guidelines trying to achieve – because that will help us have a sensible conversation.

I think they do two really positive things.  First, they treat people like adults, giving them some information about risk.  Second, by making the statement that there is no safe level of consumption they help to stop people thinking of alcohol-related problems in terms of ‘alcoholism’, ‘binge’ drinking and liver cirrhosis.  In fact, alcohol consumption at a many levels, although it might not lead to any immediate damage or produce dependence, carries a range of risks in relation to cancer and other illnesses.

That this point isn’t readily accepted is illustrated by today’s Telegraph viewpoint, which suggested government focus on ‘a hard core of [people with] health and social problems’.  We’re very quick to pin problems on other people, namely those at the visible extremes of consumption.

These guidelines are not really for those who have serious dependency or addiction issues – and to say that government should only focus on these groups to miss a large element of the harm related to alcohol in our society.

(I could discuss that Telegraph article at length, but I hope I cover most of my objections through this blog post, so I will limit myself to saying it’s hard for people to gain the sort of experience through drinking that means we “know when they have had ‘one too many’” in relation to cancer risk.)

But even if we can see these guidelines as simply helping people make informed decisions, setting them isn’t simply about science and letting the facts of risk speak for themselves.  They need to be set at a level and explained in way that makes sense to people who are actually doing the drinking.  As Alcohol Research UK point out, there’s a danger that if you set the guideline too low then people just switch off and see it as unrealistic.

But then the ‘realism’ of the guidelines depends on who you’re trying to target.  We should remember that most people drink less than even the revised guidelines (85% of women and 68% of men), so by definition they are a perfectly ‘normal’ recommendation. 

And then there’s evidence that some people change their alcohol consumption if the issue is simply raised as a discussion, without much of a push from a clinician – and the discussion of these guidelines might help with that, particularly as they plant the seed of the idea that alcohol is an inherently risky product.

So we shouldn’t assume they will be ‘ignored’ – and to some extent saying can make it so, as the guidelines depend on their public reputation for their effectiveness.

Also, although I wouldn’t use the word ‘ignored’, it wouldn’t be a failure of the guidelines if lots of people looked at them and continued to drink above those limits.  The guidelines offer information about one element of life: long-term health.  They don’t tell you how to balance up those health risks against the various pleasures you might get from the social elements of drinking, the taste of your favourite drink, or the feeling of being intoxicated.  It’s perfectly reasonable to look at the guidelines and decide to drink above them on the basis that you’re prepared to accept that risk.

But if all that sounds very positive about the guidelines, despite my genuine concern about whether they’ll be ignored, I’ll end with a couple of notes of caution.

First, there is a danger that the guidelines reinforce a policymaking model where managing risk becomes solely the responsibility of the individual, when I would argue government can reasonably play a role in reducing some of the structures that expose people to those risks.

Guidelines shouldn’t be seen as the government’s key policy contribution to reduce alcohol-related harm.  They aren’t aimed at those with the greatest level of problem, and they won’t work as an intervention for everyone.

In that way, they can be attached from both ‘sides’ of the debate.  Just as the Telegraph complains that government should instead be focusing on ‘a hard core of [people with] health and social problems’, so some public health professionals would take the opposite view and suggest that this distracts from more effective population-wide regulation measures to affect price and availability.

From the latter viewpoint, guidelines can be seen as a classic neoliberal response to the issue from government: yes, we admit there’s a problem, but it’s up to you citizens to behave as responsible individuals to sort it out; there’s no need for collective action, just information and autonomy.  The observation can certainly be made that the government benefits financially from alcohol taxes, so why would it seriously look to reduce consumption?

(Thinking of a previous job I had, I can’t help but wonder whether some of those justifying these guidelines as only information to help people make ‘informed choices’ would condemn the document of the same name produced by the Russell Group to improve access to their universities.)

But I’d suggest that although it’s worth keeping an eye on this tendency to ‘responsibilise’ individuals, it’s not an argument against either guidelines in general or these new ones in particular.

I would worry about the guidelines if I felt they let the government off the hook in relation to other elements of alcohol policy, but I’m not sure this is the case.  If we didn’t have these new guidelines, would we have minimum unit pricing?  I very much doubt it.  I can’t believe this is a zero-sum game where MUP has been traded for new guidelines.

My second note of caution is that for many involved in this issue, alcohol consumption means nothing less than a campaign.  This could be said of Gerard Hastings and Ian Gilmore, who sat on the advisory group.  This isn’t to condemn them; we need campaigners, and there’s nothing wrong with having a position, particularly when they’re so open and honest about it.  However, there’s no doubt that if they felt attention was moving away from alcohol consumption and government was becoming complacent, they would be keen to draw attention to the scale of drinking and harm in the UK, and lower limits can help to play a role in that.

But these notes of caution are really, as ever, about how healthy this debate will be in the future, not about the detail of the guidance.

When we consider what happens next, let’s maintain some balance and realism.  The best starting point might be for all those involved in the debate to remember that most people drink within these guidelines, so while there isn’t necessarily a ‘crisis’ they’re not an unrealistic idea either.

The pleasures of intoxication

My thinking on drugs and alcohol is often structured around the idea of pleasure.  I’ve written in the past about how this isn’t a terribly useful way to make sense of what we do around drugs and alcohol, as no behaviour – least of all drinking in the night-time economy – can be made sense of using such a black-and-white term.  But there is occasionally a use in having this kind of concept in the back of your mind.

As regular readers of this blog and/or my academic work probably know, I’m quite a fan of Pierre Bourdieu.  He basically argues that class is about something more than occupation, income or market position – it’s about how these attributes fit into society’s wider ‘symbolic economy’.  For the concept of class to be at all useful, it has to mean something more than any of these individually – it’s the thing that links all these and the other correlated attributes that mean we can identify someone’s ‘class’ by the clothes they wear, where they live, what car they drive and what they do for pleasure.

His work was concerned with how these different perceived groups are made, and what effect that has on our lives in terms of personal and political possibilities.  The groups are made by ‘distinction’ – features of taste that distinguish one person (and hence one group of people) from another.

Central to this mechanism of distinction is the idea that, for the bourgeoisie, form is separated from function.  For example, in relation to food Bourdieu suggests that while the working class eat food that is simple and high in calories – and eat it in a functional, unpretentious way – the bourgeoisie eats daintier food designed almost to hide the fact that the food is about taking on energy.

He builds his whole position as a ‘critique of the judgement of taste’, to suggest that the rules of ‘good taste’ always serve a social function of distinguishing people from one another, through hierarchies according to broader systems of value.

The relevance for alcohol studies is the stories people tell around their drinking – why their practices are pleasurable (and therefore valuable).  As James Nicholls notes, the pleasures of wine drinking are often quite divorced from one of the key defining features of wine: its alcohol content.  This can easily be analogous to Bourdieu’s discussion of food: some value drinks that get them drunk; others emphasise other, seemingly peripheral, features – that wouldn’t be obvious to those not in the know.

In a sense, this comes back to JS Mill’s ideas about happy pigs (or, actually, satisfied pigs).

“It is better to be a human being dissatisfied than a pig satisfied; better to be Socrates dissatisfied than a fool satisfied. And if the fool, or the pig, are a different opinion, it is because they only know their own side of the question.”  John Stuart Mill, Utilitarianism (1863)

By positing something greater than intoxication (or immediate sensory pleasure), the thinking wine drinkers place themselves on the side of Socrates in this statement.

But having read Bourdieu on the subject, how can a thinking drinker stand by this claim?  Any statement of ‘I like this drink’ to mean something more than ‘I like the taste’ can immediately be analysed to show that there is nothing fundamentally valuable in this practice other than the meanings we create for it.

(I don’t mean to advocate complete moral relativism – I am assuming that the happy pig isn’t hurting other people.  And I’m exaggerating when I write that there’s ‘nothing’ valuable in the practice.  Watching football, for example, might be said to have benefits in terms of social solidarity, getting people out of the house and so forth.  But that’s not why people experience pleasure in the practice – these positive knock-on effects aren’t what get people down to the County Ground on a cold, wet Saturday in November.)

In the face of such criticism, how can we continue to find pleasure?  As soon as we’ve thought through that our liking for ‘real ale’ is partly down to the perceived resonances with some fictionalised version of the past, surely that pint suddenly doesn’t taste so sweet (or rather, bitter)?  Saying (or thinking) these things out loud makes them seem a bit ridiculous, doesn’t it?

And in any case, you only like the taste of that drink because of the way you were introduced to food and drink, which is simply chance.

One response, of course, is to say ‘so what’?  Of course we’re products of our environment and like things that resonate with particular tastes, experiences and principles we’re familiar and comfortable with.

But that would reduce the distinctiveness of the practice.  The whole point of distinction is that ‘good taste’ is pure in the Kantian sense – it’s unsullied by function, and it shouldn’t be simply a product of our environment; it’s genuinely ‘better’ than other tastes, otherwise it’s nothing: there would be no hierarchy.

Again, you might ask, ‘so what’?  But my query now is: if this critical sociological/psychological approach was more widespread and took root in how people think, wouldn’t the ‘purest’ form of taste be the most immediate?  That is, the most genuinely ‘disinterested’ taste, that which would demonstrate one’s intellectual superiority by being able to critically analyse one’s own pleasures and place oneself outside of one’s position in social space, would be sensory pleasures.  Socrates would come over to the side of the happy pig.

This wouldn’t be such a new idea, given the ‘libertines’ of the 17^th and 18^th centuries or the status of drugs for intellectuals in the 1960s, but it does offer a way to have pleasure (and status?) for the sociologist or cultural theorist inclined to overthinking, and I can drink to that.

The concept of addiction

I've been thinking quite a lot recently about the nature of addiction.  This is prompted by an exchange on Twitter that mentioned 'functional alcoholism', and a presentation given by Mark Gilman at a recent conference hosted by the treatment provider CRI.

I'm certainly not the person to develop a new or more nuanced understanding of addiction, and this wouldn't be the place for me to do it.  But there is something I want to do here that I hope will be useful.  It's more of a general point about definitions and how we use concepts.  I wrote last week about how pleasure and happiness probably aren't very useful analytic concepts, even if they mean something useful to us in everyday conversation.

You could take an academic, intellectual perspective and suggest that concepts need clarity to ensure we have perfect, Habermasian communication.  I struggled to read and understand Habermas, but there's definitely a point something like this that should be made.

I've seen Mark Gilman talk a number of times now, and the central assumptions and conclusions of his presentations have been the same for the past two years at the very least.  One of his key contentions is that there are alcoholics or addicts as defined in the 'big book' of the fellowships.  And not simply that people who fit that characterisation exist, but they are the only people who are really addicted to substances; there might be others who drink too much for their health, but they're not addicts.  This particular group of people who are addicted are best treated using that 'big book'.

This seems perfectly reasonable, if it works.  That is, if AA or NA work for that category of people, we should absolutely be encouraging them to access these services.

I'm not going to question that evidence base here.  There's plenty of lively (and often uninformed) debate on that issue already.

But here's the rub.  When we talk about 'addiction', what do we mean?  Some people would argue that the term is so disputed and inexact that we should cease using it entirely.

But Mark Gilman would argue that he's doing the opposite of this: he's using it precisely, with a very narrow but clear definition - taken from the 'big book'.  And for these people, the idea of 'controlled drinking' could be hugely destructive.  This is certainly a different perspective from the New Directions conference I attended this summer where there was something of a retrospective on 'controlled drinking', and researchers like Marc Lewis expressed their admiration for this stream of work.

And here's where my sociological, methodological objection comes in.  I don't subscribe to some Platonic model whereby concepts pre-exist human thought and signify some kind of absolute reality (that we may or may not grasp) and we're on a process of working out what addiction 'really' is.

Instead, I'd argue that any such concept isn't god-given, but only exists as a human construct, and is only useful insofar as it helps us to understand the world around us.

And so the authors of the study I link to above are right: if 'heavy use' gets us further to understanding what's going on and how to address it, then let's stop using the term addiction as a technical, clinical term.  I happen to disagree, but at least the debate is taking place on the right terms.

By this understanding, there's no problem with the Mark Gilman approach or the 'big book' definition of addiction, but equally it's important to note that if this is 'addiction', then there's also lots of people who have something more problematic than simply drinking at a level that is harmful to their physical health who don't then 'recover' from their issues in the way suggested.

There's a further problem too: the reflexivity or self-awareness of human beings.  Concepts about human behaviour don't simply exist in a vacuum; they also reflect back and shape that behaviour.

Think of economics.  Lots of critical theories of neo-liberalism note that economics and its metaphors haven't simply described the world of human interaction; they have also shaped that behaviour by making people think not only that they do behave like 'economic man', but that they should.  We internalise the tenets of neoliberalism.

This argument is closely linked to certain claims regarding the influence of psychology - as well as trying to describe and explain our behaviour, these theories or worldviews change it.

You might not agree with the arguments in these particular examples, but there's no doubt that if you get a diagnosis of your behaviour - which is inevitably determined by a mix of structure and agency, individual choice and wider determinants - this diagnosis (knowing what you are 'like') will affect those conscious elements of behaviour.  In fact, that's one of the reasons the AA model of addiction is opposed by people like Stanton Peele: it deprives people of their agency at precisely the time when they need to be toldthey can change long-term patterns of behaviour.

I'd suggest that both those suggesting 'heavy use' as an alternative to 'addiction', and those sticking resolutely to either a DSM or 'big book' definition are playing a strange game of trying to pin down the myriad of complex ways people can experience problems in relation to a range of substances (or behaviours) into one unifying theory.  Perhaps such a debate clarifies what is actually problematic about certain forms of substance use, and how we might address this, but it also risks obscuring 'different' issues or patterns of behaviour.

And these definitions aren't simply academic.  Mark Gilman is proposing service design on the basis of segmenting the potential users of services by these categories, and DSM definitions will affect what sort of treatment people receive - or even if they receive any at all.  That means the 'accuracy' - or perhaps inclusivity - of these definitions is crucial tothe chances of recovering that individuals might have.

So by all means let's have a debate about what 'addiction' or 'dependence' or 'problem substance use' might be, but let's do this with an awareness that you can't capture such issues perfectly.  And such concepts, even if they're continually developing, aren't moving towards a more and more refined and correct definition.  Moreover, they need to be continually developed, as they're linked into a feedback loop as they impact on the very behaviour they're trying to describe.

At best, these concepts might become more useful as they develop.  My fear is that today these debates mean they're becoming ever less useful, as people in the field talk across each other and exclude certain people and understandings.

Drinking and happiness

I've been thinking quite a bit recently about happiness and drinking.  This was prompted by a call for papers on leisure and happiness I was interested in.  Initially I thought I could flog the dead horse of the carnivalesque again, thinking of drinking - or at least the night-time economy - as a form of leisure, but mulling it over I've started to wonder whether there's anything we can usefully say about drinking and happiness at all.

I've written before about drinking and pleasure, and how I can't see that the concept of 'pleasure' is much use analytically at all.  From some perspectives, notably economics, if we do something we must by definition find it pleasurable at some level.  On the other hand, if we start to try to develop the concept into something a bit more nuanced, then it falls apart.  Is anything we do solely about 'pleasure'?

I remember at school being asked a question as part of an introduction to philosophy pleasure: would you commit to spend the rest of your life in a pleasure machine?  Of course, plenty of philosophers would say no, as this wouldn't amount to 'fulfilment' (or Aristotle's 'eudaimonia'), but I've never quite been convinced it isn't better to be the utilitarian 'happy pig' than an unhappy philosopher.  It was suggested to me at school that it wouldn't be pleasurable to be connected to such a machine, as you need the lows to appreciate the highs.  But my response was (and would still be) that if that's the case, the pleasure machine is flawed.  Those lows are not pleasurable in themselves.

So immediately we have this idea that true pleasure or happiness comes from there also being 'lows' or unhappiness.  And in practice that's the case not just with opposing leisure (pleasure) to work (unhappiness and/or fulfilment) - and there's plenty of academic work on this.  In fact, almost any action, or leisure activity, is imbued with something more complex than happiness or pleasure.

If we think of drinking, the whole reason I've employed the concept of the carnivalesque is that people aren't completely happy and comfortable just feeling pleasure on their nights out.  Part of the thrill and excitement is the discomfort, uncertainty, risk and so forth.  And the feeling of drunkenness is certainly something more than simply happiness or pleasure.  There might be a stage of drunkenness people describe as being pleasurable, but it's only one element of drinking, and not many would equate it with being (necessarily) happy.

At first sight, drug use is the ideal example of something that might approximate a 'pleasure' machine - the substances supposedly stimulate our nervous system to give us chemically-induced pleasure.  But it's all a bit more complicated than that.  There aren't many drug users who would simply talk in terms of pharmacological pleasure - and as a recent posting on Points reminded me, we do actually have to learn how to find certain experiences positive rather than disconcerting and unpleasant.

But perhaps once we've done that learning, drug use might make us 'happy'.  However, I'd suggest that people's 'happiness' isn't directly related to their substance use, and they wouldn't discuss it in those terms.

And it's not just about nights out.  In leisure studies there's an idea of 'serious' leisure, where the activity as seen as requiring practice, expertise, knowledge and so forth.  It is a form of working on one's body and/or life.  Such a model of leisure might make sense of some approaches to wine or craft beer - there is a canon of knowledge the expert needs, this isn't about pleasure or even happiness quite, and there is work and distance from pleasure required to 'achieve' connoisseurship.  In fact, it's not so different to the learning and expertise required if you take the approach of Drug, Set, Setting.

Of course, one way round this analytically is to say that true 'happiness' or 'pleasure' is closer to Aristotle's eudaimonia, or fulfilment - but that's basically saying these concepts as we actually understand them are redundant.  'I was happy in the haze of a drunken hour but heaven knows I'm miserable now' only works if these are neat binary positive/negative concepts - and in this context (and most others) what it really means is momentary pleasure.  That's not eudaimonia.

Most of the time, we don't live our lives in those black and white terms - or maybe that's just me.  Certainly it's very hard to look at a particular drinking practice and say that it leads to happiness.  But maybe, again, that's just me.

Unless, of course, you're watching a drinks advert.  Certainly those images familiar from brands such as Thatchers tempt us to see drinking with friends as being a moment of happiness.

But I'm not sure that works in quite the same way for the actual drinking we experience.  I think any discussion of drinking in terms of happiness misses the point - but in exactly the same way as it would for any other aspect of our lives.  Watching Swindon Town doesn't (very often) make me 'happy' - but that's not really why I do it.  I'm not sure listening to music makes me 'happy', though some specific songs might do.  And should we be aiming for happiness in any case?  That's a question for philosophers and sociologists like Will Davies to answer.

Alcohol Concern and evidence

When I started this blog, it tended to feature swift responses to things that had been in the news that day.  These days, whether because I'm busier or lazier, I tend to be a bit slower off the mark.

A few weeks ago, Alcohol Concern published a report about trends in drinking patterns across Britain.  I found this report pretty weak and frustrating, but limited my response to a few self-indulgent tweets.  However, since then, the report has been picked up by Russell Webster, who has praised it, and so I feel that I should put down my concerns in full a bit more clearly.

First of all, I have some concerns about the sponsorship of the report.  As regular readers of this blog will know, I'm not particularly opposed to industry influence on policy, so long as that influence is clearly stated.  And influence of this kind isn't always straightforward.  I'd suggest that when tobacco companies fund the IEA, they aren't directly shaping the outputs of that organisation as much as they're making sure that a free market position has a powerful voice.  It's the same when SABMiller sponsors Demos - they know that their work is structured around ideas of 'parenting' and 'character', which suits them well, so they want to support that voice.

And so we can see the sponsorship of Alcohol Concern by Lundbeck in much the same way.  Both organisations have an interest in particular drinking patterns that are currently accepted as relatively 'normal' being labelled as problematic - Alcohol Concern because they are firm in their belief that there is no 'safe' level of alcohol consumption, and Lundbeck because they are - or were - trying to market a drug to treat a level of consumption that historically hasn't been seen as requiring any formal intervention, let alone prescribing.

So in a sense it's no surprise that one of the 'key findings' of the report was 'people who want to quit or cut down might benefit from treatments like patches or pills'.  Luundbeck, as you're probably aware, make Selincro/Nalmefene, which has within the past year been approved by NICE as a treatment for people who drink at high-risk levels but who aren't dependent.

Of course there are prescribing interventions that are useful in some cases where people want to cut down or stop drinking, but it seems odd that in a big picture style report this was seen as a major concern.  Access to medication isn't something most people in the field I speak to are too worried about.  In fact, this comes just at the point where in other comparable areas of public health - drugs and tobacco - we're seeing a possible move away from medicalised or prescribing interventions, in favour of talking therapies, peer support and innovative developments like e-cigs.

My other major concern with the findings of the report was the way it looked at alcohol consumption in isolation from other factors.

Having had a discussion along these lines with Jackie Ballard at the launch of a report on older people's drinking, I feel confident that I know why this is, and it's for the same reason that lies behind the sponsorship arrangement.  Alcohol consumption is viewed by Alcohol Concern as a problem in itself. 

I challenged Jackie on this point, suggesting that she was misrepresenting the nature of risk - we know that plenty of people consume at 'high risk' levels without suffering the levels of harm associated with this on average.  I didn't get anything like a satisfactory response, with Jackie simply stating that of course any amount of alcohol is harmful - even as we'd just been told that some of the people with the greatest longevity in the study had been drinking at high risk levels.

(And that raises another methodological issue with the report: using a chief executive as a specialist expert in the field to deliver findings such as 'There is possibly a view that wine isn’t dangerous; - I thought that was the sort of finding a study like this was meant to investigate, rather than leave it to armchair pundits to ponder what people might 'possibly' think.)

My particular concern in the context of the older people's drinking report was that the issue we were grappling with was how to communicate the dangers of drinking to people who can't see any ill effects of their habit.  We face the same problem with new psychoactive substances: if we go around saying that these substances kill people, it just won't sound credible to the people actually using them, who may have examples of 1,000s of instances of use without any serious harm.

And part of the problem with alcohol consumption and harm is the 'alcohol harm paradox', which suggests that although people from the highest income and wealth brackets drink the most, they also suffer the least alcohol-related harm. Although there's all sorts of issues with the data that go into these models (for example about the relevance of 'special occasion' drinking), one of the important points is that other factors exacerbate people's risk of ill health: it's not just a matter of controlling for various independent factors, as they interact and amplify each other's effects.

So when Alcohol Concern state as a key finding that 'heavy drinkers tend to be well educated' and 'people who drink care about keeping fit', they're in danger of directing our attention in the wrong direction.  It's particularly strange that they do this while noting in the very same section: “health inequalities in society also mean that alcohol has a relatively greater impact on people in lower socioeconomic groups than their higher earning counterparts”.

Of course, there's always politics about these discussions of what drinking is problematic.  The danger in being too vocal about how alcohol-related harm is most concentrated amongst lower socio-economic groups is that it reinforces that old view that working-class drinking is the most problematic, rather than domestic, middle-class wine drinking.

However, on the flip side, I have a huge fear that in a time of astonishing cuts to the budgets available for substance misuse treatment, we don't need attention being drawn to well-educated drinkers, when they don't experience the highest level of harm.

But then, that's because Alcohol Concern see a direct, unproblematic link between levels of consumption and harm.

For me, by contrast, we should start with the harm and address that, and if we need to use consumption as a proxy for harm, that's fine, but we need a lot more other data and it can only be a proxy.  So in fact this is more than a political point, it actually gets to the heart of what we're defining as being problematic about alcohol.  If it had no health effects, I think we'd be hard pressed to identify a definite problem with domestic consumption of alcohol, even if it led to intoxication (setting aside risks of setting your house on fire by cooking when drunk).

But the question of what’s problematic about alcohol consumption is a bigger discussion for a different day.