Thursday, 24 May 2018

Changing the narrative with personal stories

Yesterday I was at an amazing conference – InterAction 2018 – hosted by Adfam and funded by Alcohol Research UK.  The mixture of speakers was fantastic, including researchers, policy people, practitioners, carers, service users, and even a social historian.  And there was an open dialogue about key, fascinating issues, conducted in a collegiate way.

There were innumerable striking stories and insights, and each person will have their highlights.  But for me, having spent the day before sat in a meeting with health colleagues and an inspector from CQC, the story that hit home hardest was Tina Williams’ description of how her son died of lung cancer on a Sunday, having only been diagnosed on the Monday – because his health needs were not even identified, let alone met, by a system that fails people who use drugs, particularly when these substances are used to self-medicate for physical and mental pain.

The point that perhaps got the strongest reaction all day was also from Tina, when she called for providers to stop promising to commissioners that they can deliver everything desired for a bargain price.  It’s not possible and gives a false sense of security to decision-makers while giving potential service users and their families inflated expectations, and the problem has become even more acute as funding has reduced.

My response – a point made at the event by Paul Hayes – would be that I think there is actually an increasing sense of realism amongst both commissioners and providers.  I don’t think there will be many commissioners who aren’t concerned about ‘market failure’, given the publicity around instances like Bristol.  I don’t think commissioners are expecting the world from providers, and I don’t think they would get promised it either.  I don’t think areas are inundated with bids for substance misuse contracts these days – any kind of choice is seen as a vindication of the model and budget – and even the big third sector providers are reluctant to bid if they don’t already have a foothold in an area.

As part of our recent recommissioning experience in Dorset, I’ve wondered how good we are at practising what we preach.  Not just us as commissioners (talking about ‘partnership working’ and ‘open and honest’ dialogue) but practitioners.  The bread and butter of substance misuse practitioners should be ‘change talk’ – and yet how good are staff at dealing with change in their own work lives?

I’ll leave that question open, but the same theory applies to the wider ‘sector’, as we kept referring to it.  The discussions suggested that we, as providers and commissioners, have reached a stage of acceptance: we agree that we as ‘the sector’ have a problem.  That’s a really positive first step – but as with all behaviour change it leads to a second question: what are we going to do about it?

There seem to be two elements to the potential ‘solution’.  The first is immediate and practical.  Let’s have realistic commissioning, and ensure our staff and services are operating the highest quality service possible, with the widest reach and impact possible.  (The word ‘possible’ here is a way of expressing my concern about capacity/funding challenges.)

But there’s also a longer-term question: how can we fundamentally change the situation from one of limited and falling funding to one of increased resources?  Of course, as Paul Hayes would be the first to acknowledge, the political context has to be right.  But if we assume our arguments won’t fall on deaf ears, what arguments should we be making?  If ‘years of plenty’ ever return, then we won’t be the only people queuing up to argue for more funding, claiming that our cause is respectable and deserving.  We might, though, find our audience to be naturally sympathetic.

At the conference, there were effectively two sets of suggestions as to how we might make ourselves heard, both of which I’ve talked about on this blog before: crime and children.  Basically, we can win funding by suggesting that people who use drugs – I would say problematically, but I think we all know that’s a distinction that’s hard to maintain when we’re talking about stigma – are mad, bad, and dangerous to know.  That is: they’re likely to commit crime so we should treat their problem to reduce crime in order to feel safer; and/or they’re a risk to children, so we should treat them to protect the next generation, who can’t protect themselves.

There’s certainly some power in these arguments.  And there is of course that risk of stigma.  Some people might even feel that this is disingenuous: arguing that people are bad and dangerous when in fact most people’s reason for making this claim is compassion and human kindness.  Another presentation at the conference – by Mike Ashton – poked holes in the foundational NTORS evaluation of treatment, saying that it overstated its case (in the terms it defined).  Should we sacrifice accuracy in order to get the right outcome?

I won’t rehearse my moral squeamishness about this here.  Perhaps I’m becoming more hardened to political realities.  (I can’t imagine an argument for funding drug treatment based on compassion would get too far in today’s political environment, as the Home Secretary defends Stop and Search.)

What I want to ask is not whether we should stretch the interpretation of some statistics.  I want to think about the broader arguments they might be put to work for, particularly with those two points in mind: how can we provide a high quality service, and how can we get services better resourced?

In that 1990s/2000s era, crime reduction (‘tough on the causes of crime’) was the narrative that statistics and evidence like NTORS were marshalled to support.  This was powerful and secured sustainable – and even increased – funding through the National Treatment Agency for a decade.  But today, crime just isn’t such a powerful political issue, partly due to the successes of drug treatment.  As Paul Hayes pointed out, the last thing you want as a civil servant in Whitehall (and, I would add, in town halls) is to be successful.  If you ‘solve’ an issue, that means you instantly lose ministerial attention – and the funding that goes with it.

But if crime isn’t much of an issue, maybe drug-related issues still are.  The wider public doesn’t seem too concerned about drug-related deaths, but at a local level they certainly are about drug-related litter.  Where I live, for example, discarded needles are a regular front page feature of the Dorset Echo.

And yet, when this is used as a reason to explain provision of substance misuse treatment services in the area, the reaction is far from positive.  Some people who would acknowledge – even shout about – the fact that an area has an issue will object to facilities being established locally.  They just want the problem – by which they mean the people – to go away.

Some would suggest this is a particular issue in seaside towns like Weymouth, where there is a narrative that problems are brought in by ‘outsiders’ who see somewhere by the sea at the end of the train line as a good place to try to escape their problems.  But I think this issue of narrative is a universal problem for local policymakers.  People acknowledge there is a problem, and would even welcome a solution – so long as the location (unlike the original problem) is ‘not in my back yard’.

So how can we make this appeal more positive?  I was feeling less than positive at this stage.

Perhaps we need to resort to the familiar chant ‘think of the children’.  And that might well have some traction with local authorities, but even if there was a ‘magic money tree’, I’m not convinced this refrain would deliver funds for treatment for people who misuse drugs, rather than support for safeguarding processes, care services, fostering and so on.  Support to get the problem (again – actually the people) away from the children.

But as I listened to the presentation by Darren Murinas from Expert Citizens, who was astonishingly articulate, engaging and insightful while describing his less-than-ideal childhood, I was reminded of a commissioner from another local authority area complaining that people have plenty of compassion for ‘the children’ in cases of abuse – but not when these children become adults with a host of issues, including substance misuse, that are all-too-predictable.

I started thinking: why can’t we mobilise that compassion to support our services?  What is it we’re doing wrong?  Or perhaps it’s a na├»ve idea.  As I say, a politics based on compassion seems an impossible dream at the moment.

But then Oliver Standing stood up to give his personal summary of the day.  Two points from this really hit home for me.

First, for all that we can talk about the power of value for money stats, or the evidence of randomised control trials, that’s not always how politics works.  He gave the example of the new funding for work with children of dependent drinkers, and, while acknowledging that £6m shared between several local authorities is not a very large pot of money, he emphasised that it is worth considering why there’s any money being granted at all.  Oliver suggested that the key turning point from a lobbying perspective was a personal narrative: Jon Ashworth’s speech in the House of Commons about his own childhood, which moved a government minister to tears.

Second, that over the course of the day a lot of people talked about ‘the system’.  I don’t think Oliver quite said it, but my impression was of a tension between this big, abstract idea of a ‘system’ as compared to the detailed, touching, personal narratives – and the undeniable fact that this ‘system’ is made up of a range of people trying to improve their own and others’ lives.  Oliver’s point was that if we’re looking to improve that system, then we should start with one of the classic first steps in design: empathy.  That is, whether you’re designing a health system, a phone app or a chair, you should put yourself in the shoes of the end user.

So by the end of the day, I was feeling more positive.  If we’re thinking about ‘changing the narrative’ around substance misuse, the best way to do that is with some narrative of our own, and as we shape services.  Perhaps the most powerful way of doing this, at least at the moment, isn’t necessarily value for money stats or health economics, so much as personal stories.  And those are the kind of narratives we have in abundance.  Every person has a story.  Rather than complaining that drugs policy isn’t ‘evidence-based’, as many people do, perhaps we could think about the practical point: how do we actually get that change?  The first step could be to start the public thinking less about a ‘problem’ or a ‘risk’, and more about ‘people’.  It’s harder to say ‘I don’t want those people in my town’ than it is to say ‘I don’t want this problem in my town’.

That’s an idea for the longer-term question: how we secure adequate funding for this field.  But there’s also implications for today.  Those of us who work in ‘the sector’ could maybe do with thinking like this a bit more.  The ‘sector’ is also a collection of people doing things with people to help people.  These kind of narratives can remind us of what we should be doing and why.  This isn’t just sentimentality; it’s about a different way of thinking: let’s think less about organisations, and structures, and more about the most important element of treatment: individual connections between human beings.

Wednesday, 28 March 2018

What are drug consumption rooms for?

I’ve been thinking a lot about drug consumption rooms lately – often referred to in the field as DCRs.  They’ve been an issue nationally, with the debates around the Glasgow proposal as well as noises from Durham and other places.  And it’s no secret that drug-related litter has been an issue in Bournemouth and Weymouth, which my job covers, so it’s a day-to-day thing too.

The arguments are pretty familiar.  There’s not any real doubt that these facilities can have a positive impact for people who use drugs and the wider community.  However, there’s a debate about the scale of that impact and whether scarce resources are best spent on these kinds of facilities rather than other, more established, initiatives.  We’re never going to live in a utopia where everything that everyone needs or wants is funded and so these questions are real: what would we be trying to achieve with DCRs, and would it be worth it?

(For those of you who don’t follow these debates in as much detail as me, the term DCR can cover a range of things, but generally means somewhere to inject drugs under supervision.  The arguments in favour are that they reduce risks to people who use drugs as they have somewhere cleaner and safer, where someone is checking that they’re OK – but it’s not just about the users themselves, as they can potentially reduce public use and drug-related litter as well as drug-related crime.  If you want a good summary, Glasgow and Southampton councils have done great work on this.)

The view of the ACMD is that DCRs might be useful, but as part of a wider package of interventions; they shouldn’t be seen as a panacea on their own.  That is, of course, fair, but it’s not the most practical advice for commissioners who are struggling with increasing numbers of drug-related deaths, an ageing cohort of people who aren’t making great progress in treatment, and rising rates of homelessness and public injecting.  A comprehensive package of interventions would be great, but we didn’t have that in 2010, and now we’ve got cuts of 20% already, with no funding at all guaranteed beyond 2020.

So can – or rather should – DCRs be part of the picture in terms of commissioning under austerity?

When this debate comes up, it’s often framed in terms of the ‘methadone wars’ – that harm reduction has been sacrificed on the altar of ‘recovery’.  But (and I’m not alone on this, it’s not an original thought) I can’t get my head around this invented binary.  How does anyone achieve recovery without reducing the harm from their substance use?  How can giving someone advice and information about substance use be counterproductive to them achieving recovery?  Or, putting it bluntly: you can’t recover if you’re dead.

And a lot of people who use drugs are dying.  I don’t think this can be overstated – though it’s not necessarily the most powerful political argument in favour of drug treatment.

But setting aside this idea that treatment has been damaged by a focus on recovery or ‘successful completions’ (which I appreciate is some people’s experience, but it’s not mine), if we’re coming at this issue fresh, without the baggage of previous political debates, what should we do about DCRs?

Well the first point I often hear is that we should (to reference John Major) get ‘back to basics’.  If only we did needle exchange (and possibly opiate substitution treatment [OST]) properly, then there wouldn’t be these issues.  I’m informed that we’ve lost specialist needle exchanges and pharmacies offer a poor replacement.

But I don’t recognise this picture.  Commissioners find contracting with pharmacies frustrating: there’s lots of them and their local authority ‘business’ (whether needle exchange, supervised consumption of methadone or sexual health services) is a fraction of the overall turnover from NHS England or the commercial side of their work.  You can’t effectively manage a hundred contracts of this type.  The provider doesn’t care about your element of the service that much, and as a commissioner you can’t spare the time or energy to manage each one of them with the same intensity you’d apply to a specialist provider.  So inevitably the service isn’t great.

But that’s no criticism.  In fact, it’s in line with NICE guidelines, which suggest a tiered approach to needle exchange where specialist services offer the gold standard, including harm reduction advice, but we can’t provide that in every neighbourhood and indeed this level of involvement might put some people off, so we need to offer accessible facilities in a wide range of locations too.  It wouldn’t be possible to have a specialist needle exchange in every town or village in Dorset, but it’s possible to deliver this through pharmacies – though inevitably at a lower level of intensity.

I just don’t recognise the picture I’ve seen (or rather heard) painted that commissioners have lost all the structure and experience of 30 years ago, seen as the heyday of harm reduction.  Maybe it’s true elsewhere, but although we’re always able to improve our needle exchange offer, and the past few years haven’t been ideal, I can’t see that we’re moving away from specialist services to pharmacies.

If anything, as I say, I would have thought that the public health experience of having to directly commission pharmacies to do all sorts of bits and bobs that you wouldn’t have thought were the local authority’s responsibility (the morning after pill, for example) would have made commissioners more reluctant to use this as some kind of efficient escape route from the problems they’re facing.  There’s more uncertainty and less control – how’s that a recipe to sleep easier at night?

The issue is more likely to be integration – not only between pharmacies and the wider treatment system, but simply between needle exchange and more structured treatment.  I’ve been told that many service users actually prefer using pharmacy needle exchanges to the specialist services -precisely because they don’t get those hassling harm reduction initiatives or people trying to engage them into ‘structured’ treatment.

And that’s where we get to a really difficult point.

DCRs are often sold, following the ACMD argument, as an opportunity to engage people into treatment.  A DCR can be a hub for the full range of harm reduction activities and wider social interventions like housing, benefits, employment, probation and so on.  The argument is that some of the people most in need of support are going to come into this facility, so it’s an opportunity to get a whole range of ‘wrap around’ services put in place as part of a broader treatment ‘plan’.

But most DCRs aren’t just harm reduction hubs; they also offer – for example in the Glasgow proposal – structured treatment, often heroin assisted treatment.  Certainly there’s all sorts of services operating from most, from methadone dispensing to housing benefit advice.  That can sound like a great idea; an opportunity to engage people straight from injecting illicit substances to being on a legal prescription.

But equally it can sound like the opposite of what some harm reduction advocates would hope.

In Weymouth, we have brought all our services under one roof.  There used to be a site for prescribing, a site for harm reduction and group work, and a site for the criminal justice team.  And then the abstinence-based ‘aftercare’ operated from a range of sites (like church halls) that weren’t permanent fixtures.

(It’s not just austerity that brought services together; it’s also service user feedback.  One (unnamed) individual used what’s become known locally as ‘the dentist analogy’: imagine if you had to go one place to have your anaesthetic, then walk down the road to get your tooth drilled, then hop on a bus to then get the filling actually put in.  That’s what dealing with substance misuse treatment (and all the other related services) felt like to them.  Saving on rental costs by sharing premises won’t dig us out of our financial hole; one member of staff can cost more than the rent on a workable building – just check rightmove.  It’s the people that make the difference in services, and quite rightly that’s what commissioners are mostly paying for.)

So what’s the problem with bringing services under one roof, as they would be to some extent with a DCR?  Well, it means that by definition you don’t have dedicated harm reduction services; they’re operating from the same premises as the prescribing provider who will be (more often than not) part of the NHS.  So our needle exchange now operates from the Weymouth Community Hospital site.  Since it moved from a dedicated third-sector ‘drug agency’ base, the numbers accessing needle exchange there have fallen.  People, we’re told, find it intimidating to access needle exchange at the same site where they pick up their prescription.  (And equally, people who are now abstinent find it a challenge to step through the door of a facility where people are still in ‘active addiction’.)

I appreciate this is rambling.  I haven’t got (as I often ask for in the day job) a clear definition of ‘the problem’ or a proposed ‘solution’.  But that’s the point.  A lot of people (including me) are excited by DCRs, but if I’m honest that’s partly because they’re shiny and new to a UK audience – and therefore untainted and full of promise.

On this blog I’ve often moaned about how minimum unit pricing for alcohol is an empty vessel into which people pour all their (alcohol policy) desires: it’ll stop underage drinking, binge drinking, dependent drinking, excessive everyday drinking, and so on.  It’ll even revive the pub trade.

I worry that DCRs will become the same thing for drug policy: they’ll reduce drug-related litter, public injecting, blood borne viruses, crime, antisocial behaviour, and they’ll foster recovery and abstinence while they’re at it.

Will DCRs really be a harm reduction hub?  And if they are, should they also be a site for delivering treatment?  Or will that scare people off?  (Both people who aren’t ready for treatment and those who want to see a bit more stability in their lives.)  To return to my regular themes on this blog, I think we need to work out what we’re trying to achieve before we start leaping to solutions.

Friday, 23 March 2018

The future of Alcohol Research and Concern

Alcohol Research and Concern are, as you'll probably be aware, merging, and they're currently conducting a consultation on various aspects of their work to think about what the shape and aims of the new organisation might be.  They will be inviting comment on specific issues and questions and I'd really encourage people with any interest in alcohol-related issues to comment.  Here's what I wrote on treatment (you can access the original post by Richard Piper asking for feedback just by going to the home page of either organisation):

In terms of the specific questions you ask, yes I think there’s the potential for greater private/charity involvement in delivering to a wider group of people without addition state support.  Certainly our services (deliberately) focus on areas of greatest socio-economic need, so there may be opportunities to increase charity donations or encourage people to contribute to their own treatment or intervention – even if that’s just paying to download an app.  But this has (at least) two potential problems: (1) how do you ensure that it’s only those who can afford to pay that feel they have to; and (2) are you OK with this position politically/ethically in terms of diluting a commitment to universal healthcare free at the point of use?

As to whether the charity should seek to influence government, I think it’s perfectly reasonable to campaign for greater use of evidence-based programmes.

In terms of innovation, there’s not only technical stuff but also more general evidence that could make services more efficient and effective.  This means not just encouraging people to go online but also viewing their issues as part of a wider life, especially thinking about family, employment and housing.

Families can of course be crucial to recovery, as other respondents have emphasised, but there are plenty of people who are at risk who don’t have accessible or supportive family networks: family can be absent or indeed as much a part of the problem as the solution.

And while taking ‘a whole family approach’ is the current popular phrase for PHE and local authorities, this is often at root about reducing costs for children’s services.  I’m suspicious of this instrumentalism, given the experience of New Labour and the NTA failing to achieve sustainable acceptance of drug treatment using crime as a fig leaf for what was really about providing health and care to a group of people in need of support.  So there are key dangers with focusing on ‘family’: first, the neglect of drinkers who don’t live with children; and second the pathologising of all parental drinking, or at best painting it all with the same brush when in fact there are myriad problems where alcohol is implicated.

And this is the key point: although the Alcohol Concern/Research charity will inevitably be focused on alcohol – and this is reasonable as it is a specific and unique substance with its own history and policy – people relate to this substance in an infinite number of ways, in connection with everything else in their lives, and therefore any analysis, policy or treatment cannot and should not focus on an ‘alcohol problem’ that the UK has.  Alcohol may play a role in people’s problems, but that’s something quite different.  Even dependence is hard to isolate as a uniform condition, and certainly its implications vary.  It may or may not be seen as part of a wider ‘substance use disorder’.

And so my plea would be to avoid discussing ‘alcohol treatment’ as a monolith (when there will be a range of issues, and solutions must look beyond alcohol) and not to equate this with something that is designed to address ‘dependence’.  But you and your colleagues know all this already.  Good luck!

Saturday, 17 March 2018

Can alcohol policy accept moderate intoxication?

Having recently finished a draft of what will hopefully become a book chapter on the Psychoactive Substances Act, I’ve tried to clear my desk out this weekend, and came across all sorts of incoherent pencil notes on scraps of paper that were intended to be transformed into blog posts.  One of them, however, stood out.  It’s not fully formed, and it would need a lot more work to become coherent and worthy of proper publication, but it’s exactly that kind of half-baked, incoherent rambling that’s the hallmark of this blog: thoughts that aren’t neat (or long) enough to become academic articles (or perhaps even conference papers).

So here goes.  This should probably be read in tandem with my previous ramblings on the Psychoactive Substances Act, given that I think this was an earlier version of the chapter I’ve ended up putting together – or perhaps a response to it.  (I've updated mentions of the Psychoactive Substances Bill to 'Act', as it passed some time ago now.)

I think it also works quite well with a book I'm reading at the moment by Ingrid Walker.  Go buy that!

Before I start, I should state a key assumption: we’re never going to be able to pin down what the government is concerned about in relation to drinking (alcohol) into a single idea, like ‘pleasure’, ‘disorder’ or ‘intoxication’.  My previous attempt (with the ‘carnivalesque’) is a bit of a cheat to put together a whole ragbag of things (excess, disgust, class, gender, etc) and doesn’t tell the whole story even then.

As James Nicholls and others have argued, alcohol tends to become a lightning rod for broader social and political questions to be played out: freedom, agency, morality.  I saw a good example of this at the Alcohol and Drug History Society conference in 2013, where in the same session different presenters described British and French attitudes to women’s drinking in the nineteenth century.  Lauren Saxton described how the French, who were worried about underpopulation, seeing themselves as slipping behind other European powers in a kind of population arms race, expressed concern that drinking led women to be infertile, or at least to have fewer children.  Presentations from Thora Hands and Stella Moss, (on Twitter here and here) showed that the British, meanwhile, were concerned by overcrowding in cities and people’s inability to feed their families, and saw alcohol as leading people to have more children then they would otherwise – with less money to spend bringing them up because they were spending it on booze.

Previously, I've been somewhat dismissive of the idea that government has been 'criminalising' pleasure and/or intoxication, arguing that this doesn't quite capture the specific concerns it expresses in relation to 'binge' drinking.  But, as that example shows, this is because my focus has generally been on alcohol policy, where I think the situation is more complicated because of the legal status of alcohol in Britain today.  The situation is different when we look at other substances that might be grouped as 'intoxicants'.  And I think, grouped in this way, we can start to see a common thread between all of them, despite initial appearances.

The new Psychoactive Substances Act [not so new, now I'm typing this up] is precisely targeted at intoxication, and tries (pretty clumsily) to pin down a scientific description of 'psychoactivity' to do this.

In the same way, successive alcohol strategies have been targeted at those who 'drink to get drunk', also known as 'binge' drinkers.
Now this needn't imply opposition to intoxication per se, and there are certainly other societies past and present where certain limits to intoxication have been applied (rather than absolute opposition to intoxication).

We can see this in Jennifer Richards' rejection of the approach based on Norbert Elias' concept of a 'civilising process' that sees early modern writers as giving drinking advice based on opposing ideas of 'excess' and 'restraint'.  According to Richards, 'the preoccupation with restraint and excess has left the conviviality of moderate intoxication, light-headedness, and its rhetorical practice - the witty adaptation of sayings - overlooked and undervalued' (p.172).

This view would be very familiar to the drinkers of many research studies, whether the young women described by Farringdon as trying to tread a 'fine  line' of feminine drinking, or the older drinkers in Carol Emslie's work.

But today's UK government cannot see alcohol consumption or use of any other 'drugs' in these terms.  Alcohol strategies don't talk about 'fuddled joy', for example, and the alcohol industry is not allowed to suggest that drinking enhances sociability - something that many of us would struggle to argue with.

Alcohol as possible health-enhancer, alcohol as tasting good, alcohol as a valuable part of the UK economy, yes.  'Moderate intoxication'?  This, in alcohol policy debates, seems to be considered an oxymoron.  The phrase is surely unimaginable in a policy document.

The government, if no-one else, is still very much signed up to the Norbert Elias model of good and bad drinking as being about restraint versus excess, where any intoxication - or at least 'drunkenness' - is by definition excessive.  The 2012 Strategy noted that 'in moderation, alcohol consumption can have a positive impact on adults' wellbeing, especially where this encourages sociability' - but the example of how this happens has nothing to do with the 'intoxicating' or 'psychoactive' properties of the substance: 'Well-run community pubs and other businesses form a key part of the fabric of neighbourhoods, providing employment and social venues in our local communities' (p.3).

(Of course, in acknowledging the setting of drinking this government, like its Labour predecessor, was showing it is familiar with the important work of Norman Zinberg.)

This approach, whereby 'moderate' and 'safe, sensible, social' drinking cannot mention intoxication does suggest that government is concerned with mind alteration specifically.  But actually the awareness of the importance of setting and so forth reminds us that the concerns are indeed broader.  Psychoactivity gives a neat rationale and pseudoscientific position, but in reality the concerns are about things like crime and antisocial behaviour - or more widely the disruption of everyday norms (see my work on the carnivalesque where the concerns are more about 'norms' being disrupted then chemical intoxication).  The Psychoactive Substances Act effectively brings this position out into the open, by separately, as explicit exceptions, those substances that are viewed to have forms of consumption consistent with those 'everyday' norms: alcohol, nicotine and caffeine.  But even then: 'moderate consumption', yes (though not even that in terms of nicotine), but never 'moderate intoxication'.  Here's hoping for a shift in the narrative.

Friday, 2 February 2018

Accepting complexity but thinking simply

I can’t be the only person interested in alcohol policy who feels like minimum unit pricing (MUP) is in the news constantly at the moment.  Whether it’s the judgement from Scotland, the plans to introduce it in Wales, or the hearings of select committees in Westminster, it’s the lightning rod through which all discussions of alcohol policy seem to be conducted.  (As I was writing four years ago!)

This leads, sometimes, to bizarre commentaries on the issue, as people see in it whatever they want to.  Lewis Robertson suggested that the ‘temptingly simply idea’ behind MUP was to ‘increase the price of strong and inexpensive booze and it will become unaffordable for problem drinkers’.

But that’s not really what it’s about – or at least it’s only one interpretation.  For a start, MUP isn’t about making alcohol ‘unaffordable’; it’s based on the fact that, for most goods, we buy less of them if they become more expensive.

But more important than this quibbling is the question begged by the phrase ‘problem drinkers’.

James Morris has been vocal on this issue for years, and recently got good coverage in The Guardian, arguing that we should be wary of the term ‘alcoholic’, because it leads us to picture a specific kind of person when alcohol is linked to a whole range of issues amongst a whole range of people.

Is MUP really designed to target ‘problem drinkers’?  And if it is, then who are these people and what is the ‘problem’?

I’d suggest that, fundamentally, we don’t know the answer to either of these questions.  In Scotland, the campaign for MUP has been founded on an acceptance that Scotland has a national, cultural problem with alcohol – and I’d suggest that’s why the initiative has had reasonable levels of public support.

In England, it’s been more likely to be presented as a way to address issues with specific ‘problem’ drinkers – notably street drinkers or young ‘binge’ drinkers (as in David Cameron’s foreword to the 2012 Alcohol Strategy).  This is why I argued at the time that English discussions of MUP were still couched in neoliberal terms: MUP wasn’t seen as a population-wide intervention to deal with a problematic substance; it was a ‘targeted’ initiative to deal with individual ‘flawed consumers’, as an academic sociologist might put it.

And this is why MUP is the perfect lightning conductor for all the old arguments about alcohol.  It can be all things to all people.

And so on to the usual conclusion of this blog: if we can’t agree on what the problem is, how can we agree on a solution?

And I don’t think we’ll ever agree while we see things in black and white.  Increasing the price of some alcohol isn’t about making it ‘unaffordable’, as Lewis Robertson would have us believe – but equally, because it’s about making it a bit less affordable, it will have some effect on lots of drinkers.  And while that effect is more likely to be felt by heavier drinkers whatever their class/income, it’s still true that the poorer you are, the more likely you are to be affected by these price changes.

And we shouldn’t seek some resolution to the ongoing debate of whether the ‘problem’ with alcohol sits with the substance or particular individuals.  (I recommend reading Ron Roizen on this from a US perspective.)  That’s the old argument of structure versus agency.  As Marx (almost) put it, we make our own decisions, but not under circumstances we’ve chosen.

So here’s my summary (at the risk of repeating myself and others not just wwithin this post but over a number of posts):

  • There are a number of problems that can be associated with alcohol.
  • They are not all best described as ‘alcoholism’ or even ‘alcohol problems’.
  • However, the control or removal of alcohol might help lots of them.
  • There are infinite potential causes of and influences on these problems.
  • There are many potential solutions.
  • MUP is a potential solution for some, but not all people and problems.

And I’d like to leave you with a final, embryonic thought that needs some development of its own, which I’ll do maybe some other time.

Over the past few weeks I’ve been thinking a lot about the idea of complexity.  There was an article in The Lancet about how seeing a problem as ‘complex’ can lead to inaction in addressing it, as it’s seen as to difficult or unmanageable.  (For those from a treatment background, think of ‘complex’ individuals, or dual diagnosis.  For policy wonks, think of ‘wicked’ problems.)  Then I came across an article from a few months ago about how in policy debates industry representatives often employ the idea of ‘complexity’ to block activity.

In my day job, I try to cut through these discussions of ‘complexity’ to focus on what we can actually do, but of course on this blog I often find myself, possibly in a self-indulgent way, taking the academic high ground by complaining that things are more complicated or nuanced than some commentators would have use believe – as I’ve just done here in discussing MUP!

So obviously my solution is compromise.

I’d suggest that at the same time as embracing the complex, uncertain balance of structure versus agency, and the myriad of problems associated with alcohol, we should also grab hold of some simplicity where we can.  In fact, if done right the acknowledgement of complexity can lead to greater clarity.

Let’s think about what this might mean for the issue of alcohol policy and MUP.

I’d like to see a debate where MUP is seen not as the only show in town, and not particularly linked to other interventions.  As I’ve suggested, lots of academics and policymakers like to see things as interconnected and part of systems.  This is of course true, otherwise sociology wouldn’t exist and we’d probably study something like individual-ology.  (Or perhaps just psychology.)  But we’re sometimes guilty of making connections that aren’t relevant.  Not all ‘alcohol’ problems are the same, or even particularly connected.  I’d like to discuss MUP simply on its own merits, without a consideration of whether focusing on it detracts from arguments about whether treatment systems have enough resources.*

As I’ve already admitted, I’m guilty of this.  When I’ve spoken about Dry January I’ve usually highlighted my concern that this focuses too much attention on individual solutions.  As Ron Roizen points out, although public health advocates might think they’re avoiding stigmatising ‘problem drinkers’ by suggesting that alcohol is an inherently problematic substance, the flipside is that those without problems can then reasonably explain that because they don’t have any issues with this terrible stuff, they must have good self-control and have employed the right strategies – and we’re back to ‘alcoholics’ being ‘flawed consumers’ where the issue lies with them.

There is no escape from these binaries unless we simultaneously embrace complexity and reject the idea of single solutions.

*This is a link to an excellent post by Phil Mellows.  I’m linking not because I’m critical; I completely agree that we need to look upstream to the root causes of alcohol problems (that’s exactly what I’m trying to say in the bullet points above).  But I want to make it clear that we can have MUP for population-wide reasons, for example, without seeing it as a trade-off against treatment for dependent drinkers.

Wednesday, 15 November 2017

Is your drinking like meat and potatoes?

As I noted recently, I’m maybe not as quick on the draw with these posts as I used to be, but I hope they’re still interesting (and maybe even useful) when I do manage to write something.  (And this time, as I'm able to release this post as minimum unit pricing is in the news again, as we wait for the latest court judgement.)

Minimum unit pricing was in the news again a couple of weeks ago, because of the announcement that it was being considered for Wales.  There are lots of angle to this, and most of them re-hash arguments that are ongoing and will never be resolved even if and when such policies are introduced in the UK, as ‘real world’ evidence on the impact of a policy is just as questionable as ‘modelling’, given that no policy is implemented in a vacuum.

What I want to think about is the impact on pubs, because this was specifically discussed with me by a few people on Twitter.

The key argument was put to me most clearly by Chris Snowdon, who pointed me in the direction of a post of his that features a neat and illustrative analogy based on meat and potatoes (or meat and rice, really).  The point is that as the price of rice rises, people on low incomes in China don’t buy less rice and switch to other things; they buy even more rice.  How can this possibly be, given the laws of supply and demand?  Well, they have a fixed income and rice is a more efficient thing to eat than meat, for example.  The lesson is that when times are hard, you buy less of the luxuries, and consolidate the essentials.

The argument is that a pint of beer in the pub equates to the meat in this analogy, while beer bought to drink at home is the rice or potatoes.  As Chris notes, if MUP raises the price of home drinking there are lots of ways people might respond to this (they could reduce their home drinking to maintain the number of their pub visits), but it’s pretty unlikely that spending on the ‘luxury’ of pub beer is going to increase.

Before anyone gets too technical, I want to point that I’m going to set aside the question of how likely it is that MUP would affect most people’s home drinking costs significantly, as I think that’s deserving of its own, proper, detailed discussion.  I’m just going to assume that there would be some noticeable effects that would be worth considering and potentially responding to for most drinkers.

As I said, I really like how neat and clear the analogy is (and he explains it better than me), and I think a key issue with policies like MUP is that they potentially de-normalise drinking alcohol, which of course could have a negative effect on pubs but also on drinking styles more generally.  However, I just don’t think the underlying assumptions behind the analogy hold for most people when we think about it in a bit more depth.

The key point is that there is a huge range of ways in which people consume alcohol, and how they think about this consumption.  And in fact I think there are some weaknesses or gaps in the Sheffield research on MUP, in terms of how the modelling takes account of these potential differences.  I think the Sheffield group would probably admit that although they look at on-trade vs off-trade consumption and prices, the impact on the pub industry specifically hasn’t yet been modelled in as much detail as it could be – possibly because this hasn’t been a specific priority of those who have funded the research.

But let’s think back to the meat and potatoes of the issue.  This is a persuasive analogy for certain sorts of drinkers and certain sorts of pubs, but you have to have a very specific view of alcohol that I’m not actually sure most of the population – at least consciously, or perhaps more accurately openly – would acknowledge.

When Chris Snowdon talks about drinking, he’s envisaging someone rather similar to the imaginary health-conscious unit-counter: someone who is (whether consciously or not) viewing alcohol as a single thing.  But plenty of sociological research would suggest that this is a pretty unusual position to take.

First off, most people don’t talk about their drinking in terms of ‘alcohol’.  In my research, most drinkers were keen to downplay the idea of units or alcohol content, instead emphasising behaviour or time spent in the pub/club.  For example, one man in his thirties noting that he and his friends were less likely to cause trouble than 18-year-olds who had two pints of ‘Stella’, even though they’d been drinking all day and consumed a huge amount of alcohol.  Very few people I spoke to expressed any ideas close to counting units, drinks, or even expenditure.  Most felt that the whole idea of counting was at odds with relaxing and having fun, and even those that made an effort to try this admitted that their efforts never worked in practice.

But this is a small, particular group of people, at a particular location and a particular moment in time.  There’s certainly the possibility that 18-24 year-olds today are more likely to be counting units, calories, and anything else they can lay their hands on, if there’s an app for it.

But most importantly, if we’re trying to think about the impact of MUP on pubs specifically, this all comes down to what people see a pub visit as being.  Is it actually the same category as home drinking, or is it more about going to a quiz, going out for a meal, playing a skittles match (you can tell I live in Dorset), or simply meeting up with a particular group of friends?

In research on drinking – and interestingly the Sheffield group themselves are doing some work on this more qualitative side of things – people tend to be clear about having different approaches to drinking depending on who they’re with, when and where.  It’s the old ‘Drug, Set, Setting’ approach.

If you think about it, as with most social research, this intuitively makes sense is something you already know.  (I’m trying to avoid saying that social research is pointing out the bleeding obvious, which is difficult, having listened to quite a bit of Thinking Allowed recently…)

It’s quite easy to imagine a regular drinker who always drinks beer when he goes out to the pub, but mostly drinks wine at home.  I know plenty of drinkers like this, and I’m not sure they’d think of the two things as being particularly linked, or as home wine and pub beer as coming from the same ‘budget’.  The beer is more likely to be up there with cinema visits or meals out.  Sure, if MUP had a serious effect on their household budget it could affect drinking out, but not necessarily any more than it would affect going to the cinema.

It might be that the beer drinkers for whom the meat and potatoes analogy makes sense are precisely those keeping many pubs open.  And in fact I think I’m one of them, as I only really drink beer, I go to the pub about three times a week and drink at home in between.  But I think it’s worth noting that, across the population – and even just looking at drinkers or people who go to pubs – these beasts are a rare breed.

For this to be about switching forms of consumption, the beer drinker has to be consuming a decent amount of beer both at home and in the pub.  In Chris Snowdon’s analogy, the beer drinker is having 10 beers a week.  Let’s assume these are 2.3 units, which would be a pint of 4% beer, which is on the low side for lots of people, but then you might only be having 500ml bottles at home, and equally some people might drink some beer marginally below 4%, for example – like Butcombe’s Rare Breed I just linked to.  That would be 23 units a week, just placing you in the ‘increasing risk’ category (according to the old definitions) whether you’re a man or a woman, which means that you would be in the top 26% of drinkers in terms of your consumption.  (I’m basing this analysis on the Sheffield report that underpins the Welsh Government’s decision.)

Sure, that group of ‘increasing’ plus ‘high’ risk drinkers accounts for 65% of the money spent on alcohol, but that sort of illustrates my point: pubs (and the industry more broadly) are relying on a small section not only of the population, but a small section of drinkers.

The analogy simply doesn’t fit how most people think about alcohol.  Like I say, I’m one of that ‘rare breed’, and perhaps that’s more likely amongst people who have a particular interest in the subject of alcohol policy – we’re more likely to think and write about ‘alcohol’ – and so this idea has a tendency to dominate debate.

That’s true whether you’re the Institute of Economic Affairs calling for a flat rate tax on ‘alcohol’, the Scotch Whiskey association claiming that ‘a unit is a unit’, or public health professionals arguing that people should count their units.

But actually, ‘drinking studies’ academics would be quick to point out how varied understandings of different drinks and drinking occasions can be.  Champagne is not the same as Stella Artois or WKD.

And more than that, we know that in public health terms a unit quite definitely does not simply equal a unit.  The drug, set and setting affects the effects.

Now maybe this idea of alcohol being alcohol and a unit being a unit is seeping into the public imagination, along with the tendency to monitor yourself and count things like ‘steps’ that I mentioned earlier.  But it’s certainly not how all people in all societies have thought of alcohol.  Countries like Germany and Russia have taken a different legal approach to drinks of different alcoholic strengths and I’m yet to see much evidence it’s how most drinkers in the UK think.  Certainly in terms of regulation we tax them quite differently, and licensing has long thought of premises in different ways depending on what sort of thing they sold – a beerhouse was most definitely not a tavern.

Of course, a key challenge here is whether what people say matches what they actually do, and whether MUP as a policy works at a conscious or unconscious level.  But it’s certainly worth considering.  Meat and potatoes both sit in the same analytic – and probably budget – categories of ‘food’, and they’re often purchased in the same place at the same time, or at least in the same trip.  What I wouldn’t feel confident about is whether most people, most drinkers, and even more specifically most regular pub-goers, think of drinks at home and in the pub as being in the same category.  That’s the key question.  Is this an issue of meat and potatoes or meat and washing powder?  Or even meat and Netflix?

Friday, 27 October 2017

Fitter, no happier, but more productive

In the past couple of weeks I’ve not been drinking any alcohol.  This isn’t part of any grand plan; it’s just for a short period of time for some personal health-related reasons.  As I’m not generally much of an advocate for Dry January or Go Sober for October, it’s an interesting experience, which I wouldn’t otherwise have chosen.

I won’t deny that I seem to be fitter and more productive.  I don’t weigh myself, but I seem to have lost a bit of weight – which is particularly surprising given that I haven’t been able to exercise because I broke my toe three weeks ago.  And I’m more likely to tidy up the kitchen at the end of the evening rather than just leave it for the morning (or, more likely, the following evening before doing the next round of cooking).

That’s all great, but what about that third element of the Radiohead song: being ‘happier’?

Well, in some ways now isn’t the best time to ask, as work is far from perfect and my home life is facing some particular challenges (the reasons I’m off alcohol in the first place).  But actually, that’s precisely what’s been interesting about the whole experience.

Basically, I have an unusual energy and focus.  I feel a little bit like I’m back at school, working hard, being responsible and disciplined.  But, like at school, it’s not making me very happy.  And that’s because having energy and focus without a goal is worse than simply being apathetic.  You’re a conformist without a cause.  That is, for me, one of the positives of alcohol: it distracts.

For some people this is a failing from a moral perspective.  The sort of people who see substance use as a ‘shortcut’ to pleasure, which doesn’t offer real fulfilment.  Personally, I am unsure what ‘real’ fulfilment would be, given that anyone who has ever had goals knows that achieving them offers something less than satisfaction.  Life, for better or worse, goes on, as writers and philosophers throughout history have known.

For Dostoevsky, the answer to the illusory nature of achievement seems to be the love of a good woman and a bit of religion.*  And maybe, as I’ve written before, ‘just surviving is a noble fight’.

Alcohol, as used by many people, is a variant of Dory’s famous mantra: ‘just keep swimming’.  I was once warned ‘don’t think too much’, and alcohol (on the surface and in the short-term, at least) helps stop that.  To quote another 70s soft rock classic, ‘don’t let the sound of your own wheels drive you crazy’.  In fact, that’s precisely what mindfulness is intended to do, for better or worse.

And rather than just being a personal moan, I want this piece to have a broader point, linked to my previous blog post about how drug-related deaths are about more than just treatment services.

I’ve always been suspicious of the idea of ‘aspiration’ in political discourse.  Blairites offered is as a warning to anyone proposing policies that weren’t carefully triangulated and safe.  The implicit definition of ‘aspiration’ according to this approach has always seemed materialistic to me – that people want more money, or more stuff, and they’ll just stay docile if a ‘rising tide lifts all boats’.  Don’t talk about redistribution because people want to believe that someday they’ll be millionaires.  (This is usually presented as a patronising lecture from one well-meaning, middle-class, top-down politician to another, complaining that they don’t understand ‘ordinary’ [read ‘working-class’] people’s ‘aspirations’.)  And when it’s not in the hands of third way politicians too scared to talk about their actual beliefs, ‘aspiration’ as a concept is worryingly used to explain poverty as being caused by a lack of aspiration.

But to bring this back to my moan, I think what I’ve found difficult is that without the distraction of alcohol (and I mean the trips to the pub as much as the actual substance – given that this is about ‘set’ and ‘setting’ as much as ‘drug’) I’m lacking ‘aspiration’.  My increased fitness and productivity is without purpose, as there’s too much other stuff going to enable me to feel any happier.

This isn’t a blinding insight, and I certainly don’t want this to read like a ‘poor me’ post.  I’m well aware that there are plenty of people around me who are worse off.  My point is simply to note that a lack of ‘aspiration’, or visible, achievable life goals, is pretty common and not clearly related to substance use.  The fog does not magically lift and a ‘purpose’ appear; and even if it did, most of the barriers to this are still there whether the alcohol is or not.

Now I want to be clear that I am not comparing my situation to an ‘addiction’ or ‘substance use disorder’, or whatever your preferred terminology is.  Neither am I suggesting my life is terribly traumatic or hard.  But that’s precisely the point.  Something we know to be true is quite rarely applied to broader policy issues: we often fail to think of people as a whole person, in a wider social context.  Banal, perhaps, but given my previous post it struck me that it’s still surprisingly worth saying.  Remove the alcohol (or other drug) and, as I’ve written before, that’s all you’ve done.  Too narrow a focus on substance use specifically, and how it is problematic in itself, doesn’t help anyone.

Addition @ 4.45pm:

After an exchange with Aveek Bhattacharya, where we agreed that part of the challenge with going alcohol-free is that pubs - and therefore alcohol - are the default option for socialising and evening activities, I got thinking about specifically why I haven't gone to the pub much.

It's not just that I don't see their appeal when I'm not drunk; I often stay for a drink when I'm driving, and either eke out a small amount of beer or have coke, which I'm not particularly fond of.

And I don't think it can be that the mark-up on soft drinks offends me specifically - it's always cheaper to stay in if you just want to drink.

I think it's something about what I see as the specific appeal of the pub: not just that it's a different atmosphere from drinking at home, but that you're drinking something different.  This might not be the case for everyone - often people might prefer the wine they have at home, or the gin and tonics they make themselves, and I don't know whether Fosters on draft is somehow more exciting than from a can.  (I do, actually - there's plenty of research on the Drug, Set and Setting line that notes that the type of glass and the space you're in affects what you taste.)  But for me, I think the struggle is getting interested in going somewhere to drink Becks Blue when that is precisely what I have available at home, but for a fraction of the price.  I just can't compare bottled beer with cask beer, and most of the pubs I go to feature beers that I can't (or don't) generally buy in bottles anyway.  But maybe I'm a special case.

*I was going to put this quote in the body of the text, but as I was typing it out I wanted to include so much that it’s better here.  It’s from Notes from the Underground:

Man is a frivolous and incongruous creature, and perhaps, like a chess player, loves the process of the game, not the end of it.  And who knows (there is no saying with certainty), perhaps the only goal on earth to which mankind is striving lies in this incessant process of attaining, in other words, in life itself, and not in the thing to be attained, which must always be expressed as a formula, as positive as twice two makes four, and such positiveness is not life, gentlemen, but is the beginning of death.  Anyway, man has always been afraid of this mathematical certainty, and I am afraid of it now.  Granted that man does nothing but seek that mathematical certainty, he traverses oceans, sacrifices his life in the quest, but to succeed, really to find it, dreads, I assure you.  He feel that when he has found it there will be nothing for him to look for.  When workmen have finished their work they do at least receive their pay, they go to the tavern, then they are taken to the police-station – and there is occupation for a week.  But where can man go?  Anyway, one can observe a certain awkwardness about him when he has attained such objects.  He lovesthe process of attaining, but does not quite like to have attained, and that, of course, is very absurd.  In fact, man I s a comical creature; there seems to be a kind of jest in it all … And why are you so firmly, so triumphantly, convinced that only the normal and the positive – in other words, only what is conducive to welfare – is for the advantage of man?  Is not reason in error as regards advantage?  Does not man, perhaps, love something besides well-being?  Perhaps he is just as fond of suffering?  Perhaps suffering is just as great a benefit to him as well-being?  Man is sometimes extraordinarily, passionately, in love with suffering, and that is a fact.