British Drug and Alcohol Policy: V. What is “Recovery” from Addiction, and Can Medications be a Part of It?

Much of why public policy moves as it does from generation to generation and from place to place can be attributed to simple, well-articulated ideas that guide all the players both explicitly and implicitly. “Addiction is a sin and a sign of God’s disapproval” is one such influential idea. “Addiction is a chronic medical illness” is another. An idea that is currently profoundly shaping drug and alcohol policy developments in a number of countries, and in a way I consider very positive, is that there is something called “recovery” and policy should try to bring it about more often.

But what is it? Bill White finds U.S. precursors going back in the history both of Native Americans and the European immigrants of prior centuries, but its modern forge has clearly been 12-step organizations such as Alcoholics Anonymous. They posited that recovering from addiction involved not only cessation of substance use but also restoration of emotional and spiritual health and responsibility to others. AA has been misunderstood, including by its own members, as saying that every addicted person must go through this process. In fact, the founders believed the evidence of their senses that many people who drink too much can put the plug in the jug full stop (or cut back and “drink like a gent”), and live good lives without further reflection. But AA’s founders also believed was that whoever those problem drinkers were, it wasn’t them; they needed something more.

Over the past 15 years or so the definition of recovery in the U.S. has broadened to include recovery from mental illness and to recoveries from addiction via routes other than AA, including other self-help organizations, psychotherapy, addiction treatment programs, faith-based organizations, self-change and yes, medication-assisted treatment including anti-depressants and methadone. Not being in recovery myself I stand in awe of those who have had their lives saved by one route of recovery but have gained the maturity and perspective to acknowledge that their way is not the only way.

Politically, this has transformed the recovery movement from a group of battling sects to a genuine force for change in the U.S. and increasingly, in other nations as well. Among its political demands, pushed by organizations such as Faces and Voices of Recovery and Legal Action Center and adopted as policy in President Obama’s National Drug Control Strategy, is that government should remove barriers to addicted people entering and staying in recovery, including the withholding of student loans, employment, housing and other benefits from people who been convicted of drug-related crimes during their period of active addiction.

The Betty Ford Institute held several influential consensus conferences of thought leaders that defined recovery as follows: A voluntarily maintained lifestyle characterized by sobriety, personal health and citizenship. The use of medications was explicitly accepted as a potential part of that equation (contrary to stereotype, Betty Ford Center participated in the Clinical Trials Network study of buprenorphine and are not anti-medication zealots). The BFI definition and working papers really did echo around the world, attracting some criticism but moreso being regarded as a breath of fresh air.

In recent years the recovery movement and its ideas have crossed the pond, and as far as I can tell the first interest came from Scotland. As one government official put it to me in Edinburgh, “Focusing on recovery gave us a chance to move beyond the stale, endless and unproductive arguments between radical abstentionists and militant harm reductionists”. Scotland adopted a recovery-focused policy framework, and as part of that made extensive contact with colleagues in the U.S. who were pursuing the same goal.

The Scotland Futures Forum devoted to Recovery is available on line here and if you watch one thing I suggest you see Bill White’s talk and his follow-up one on one interview. What cannot be completely captured on the film is the spirit of the audience. Continue reading “British Drug and Alcohol Policy: V. What is “Recovery” from Addiction, and Can Medications be a Part of It?”

Freedom of Information for Criminals: A Great Idea

After reading my post on 24/7 Sobriety, the criminologist David Kennedy was kind enough to send me a copy of Deterrence and Crime Prevention. His book is a tour de force not just for its intellectual value, but for its wisdom about why people do the things they do (cops and robbers both). One of the many valuable lessons of the book is that a good deal of crime can be prevented simply by giving criminals better, simpler information about what the rules are.

Kennedy gives the example of a young gang member with several prior convictions who did not realize that his next gun-related arrest would result in a long federal sentence, and ending up being sent upriver for 15 years for a minor violation (possessing a bullet). A number of other gang members then came in to check with the police to see if they were in the same legal situation and many found out to their surprise that they were. Some law enforcement officials might say “In revealing their status to them the police gave up the chance to send them away for a long time, like the guy with the bullet”. Exactly. The chance goes away because the criminals didn’t carry guns and bullets anymore, i.e., they were deterred once they understood what the rules were.

But deterrence isn’t the only reason to lay cards on the table with criminals. If you had a robot that punished with 100% accuracy every violation of any rule you imposed on your children, would you still tell your children the rules in advance, given that punishment would be perfectly applied with no effort on your part? Of course you would, because you care about your kids and therefore don’t want them punished unnecessarily. When your kids see you take the time to tell them the rules, they know that you care. Many criminals live in neighborhoods where the dominant narrative holds that cops/judges/majority society hate us. When a police officer or judge or some other law enforcement official takes the time to help them understand the rules, it undermines that narrative by showing that someone in authority cares about them. When people feel cared about and that life isn’t rigged against them, they are less likely to lash out and be destructive to themselves and the people around them.

To come back to 24/7 and HOPE probation, both programs have simple rules that are explained transparently to offenders at the outset. This contrasts with the usual situation in court, which is an offender being baffled by the proceedings and hoping meekly to escape punishment. The rules of the courtroom, probation and parole are complex even for the professionals, and the average criminal has lower education, IQ and literacy than the general population. Anyone who has been in court has seen a judge ask a defendant “Do you understand?” and seen the defendant look over at his/her lawyer for a cue, get a nod, and then say “Yes judge, I understand”.

From what I have seen, offenders in 24/7 and HOPE do understand the rules, and have the sense of being cared about, most particularly that the judge and the staff actually want them to succeed, which may be a key reason why most of them fact do succeed. And strikingly, even when they don’t, they typically draw the conclusion that is better for them and society: “I got punished because I screwed up, better not do that again”, rather than “I don’t know why I got punished but I know it wasn’t fair and someday, somehow, someone’s gonna pay”.

British Medical Association Selects ‘Drug Policy and the Public Good’ as Best Public Health Book of 2010

I get more than the usual narcissistic pleasure an award brings from this considerable honor bestowed by BMA. It took almost five years for our team of 12 researchers from 7 countries to write Drug Policy and the Public Good. The process was stimulating but also, frankly, arduous. In many areas, drug policy research doesn’t give an empirically clear enough picture to overcome differences in political views and national predilections, leading even intelligent people of good will who like each other to argue (and argue and argue and argue, I am fortunate not to have lost my friendship with Robin Room as a consequence of this book). The end result is a book that each author disagrees with in some specific parts, but in general reflects hard-won consensus of what the international scientific base says.

p.s. The profits from this book go to the Society for the Study of Addiction, a registered charity in the UK.

British Drug and Alcohol Policy: IV. The Controversy over Methadone

Although a number of drugs cause problems in the UK, the country is remarkable among developed nations in the extent to which heroin dominates as the primary illegal drug. The main treatment response to the heroin-addicted population in recent years has been to dramatically expand methadone maintenance.

According to Professor Susanne MacGregor’s new book on drugs in the UK, the number of drug users in treatment in the UK has grown from 67,000 in 1994 to about 200,000 in 2008, at a cost to the National Treatment Agency of £398 million pounds (This is NTA’s “ring-fenced” budget in 2007/08). Most of this treatment is methadone provided to heroin addicted individuals. The extensive use of methadone coupled with the closure of many residential rehabilitation programs that do not prescribe medications generated a firestorm of criticism against the Labour government. With the arrival of a new government, the critics have receptive ears into which to speak, and an overhaul has been promised.

The criticism of UK methadone maintenance has several strands which are important to untangle. One is that the care in UK methadone clinics is often of poor quality. Researcher David Best has documented that a patient who spends an entire year receiving methadone might get a few hours of counseling, total. Clinic time is devoted to providing, managing and recording the methadone dose and doing other paperwork, with almost no attention given to what should be a staple of drug treatment: Trained, concerned staff members taking a genuine interest in patients as individuals, finding out what is happening in their life and helping them tackle the problems they face. Another serious problem is the lack of careful monitoring for continued use of illegal drugs, which in some cases seems to reflect a mentality that a little less street heroin consumption is a good enough outcome because it might translate into less property crime. I have heard no one in the U.K. (on either side of the methadone debate) disagree with the proposition that methadone services in the UK have serious quality problems.

The second strand is more philosophical, and is reminiscent of the cultural battles that occurred in the U.S. in the late 1960s and 1970s over methadone vs. “drug-free” treatment. A significant camp in the U.K. objects to methadone on principle, arguing that a methadone patient is still a drug user, and therefore has not achieved the desired outcome of substance-free living. Iain Duncan Smith, MP and the Centre for Social Justice (An influential centre-right think tank) are most associated with this viewpoint, which also resonates to a certain extent with the woman on the Clapham omnibus. Smith is now heading the Department of Work and Pensions and I am led to understand that his Cabinet Committee on Social Justice will make addiction a signature issue. One still hears fundamental philosophical objections to methadone in the U.S., but they have become less common as recovery organizations (e.g., 12-step fellowships) have enjoined their members from “playing doctor”, historical research has shown that AA founder Bill W. asked methadone pioneer Dr. Vincent Dole if he would invent a methadone for alcoholics, and well-known recovery advocates like Bill White have endorsed the principle of “many pathways to recovery”, explicitly including medication-assisted treatment (This is also the position of President Obama’s National Drug Control Strategy).

The third strand of methadone criticism in the UK is political. Some conservatives in the U.K. and the U.S. believe the expansion of methadone prescription without concurrent monitoring of drug use via urinalysis (or even, apparent concern about it) is a sign that “left-wing harm reduction extremists have captured the UK treatment field”. This raises the stakes in their eyes because this becomes not just about policies they don’t like, but about people they don’t like and want to battle politically. I have friends among these critics, but with respect I think they have misread the situation, for two reasons. Continue reading “British Drug and Alcohol Policy: IV. The Controversy over Methadone”

British Drug and Alcohol Policy: III. What is Minimum Pricing of Alcohol and Will it Reduce Problem Drinking?

Although it is often asserted that “alcoholics will do anything to get their drink”, there is overwhelming evidence that even the heaviest drinking segment of the population responds to increases in price (A scholarly and readable summary of the scientific literature in this area was recently produced by the estimable Phil Cook). People who are physically dependent on alcohol show less elasticity in their demand than the rest of the population, but still nonetheless drink less than they would otherwise when alcohol is more expensive.

The converse is also true, as the U.K. experience shows: Very cheap booze will produce a rise in excessive drinking. Many UK supermarkets sell alcoholic beverages below cost as a loss leader, and licensed outlets often sell very cheap drinks during promotions, e.g., happy hour or ladies’ night (“It takes some seed to attract a flock of birds” as a landlord on the Strand explained it to me).

Many U.S. public health advocates therefore consider raising alcohol excise taxes the best way to reduce problem drinking and the health and social damage it does. In a number of the Commonwealth Countries, including the U.K., an alternative approach known as minimum pricing is gaining traction. Minimum pricing is based on a system of standardized “units” of pure ethanol (in the UK it’s 10ml or 8g) such that larger volumes of low alcohol content beverages are equal to small volumes of high alcohol content beverages (i.e., a third of a pint of 5-6% beer = half a glass of 12% wine = one measure of 40% whisky).

Because heavy drinkers pay far less (about 80% less, according to research by Bill Kerr and Tom Greenfield of the Alcohol Research Group) per unit of alcohol consumed than does the rest of the population, setting a minimum price is intended to concentrate the consumption-reducing effects of increased price on that subset of the population whose alcohol use poses the greatest risk to themselves and others. Minimum pricing also has a characteristic that makes it more politically palatable: It’s not a tax. The merchants keep all the money from the sale of minimum priced alcohol, and hence are less resistant than they would be to taxes that went to the government (Case in point: Tesco has endorsed minimum pricing ).

You might wonder why the U.K. government is considering minimum pricing instead of taking the simpler step of banning below-cost sales of alcohol. A number of politicians have proposed this, but it is probably not feasible. It is very hard for regulators to determine the true cost of production, and, under EU trade harmonization policies, it is not clear that banning below costs sales is legal (As I described in an earlier post, EU harmonization is tending to make legal alcohol more available and legal cannabis less available in member states).

I have seen news reports claiming that Saskatchewan has cut binge drinking by implementing minimum pricing, although a rigorous study by a disinterested researcher is apparently lacking (I am given to understand that Tim Stockwell, a well-respected alcohol researcher in British Columbia, is on the case, so I hope for better data in the future).

A minimum pricing law missed passing the Scottish parliament by a single vote this June. My mother’s family is Scottish (MacNabb tartan at left) and I enjoy the country and the people very much, so I hope I will be forgiven for indulging a bit in stereotype by saying that it takes some courage for politicians to vote to deny the Scottish people a discount. Nonetheless the idea still has legs in Scotland and may come up for a vote again soon.

Simon Moore of Cardiff University believes that minimum pricing’s possible benefits have been oversold. He and I and some other researchers debate this point in the current issue of Alcohol and Alcoholism. His particular worry that minimum pricing will cause heavy drinkers to switch to other substances, e.g., benzodiazepines, I think will apply only for a small number of very troubled drinkers and not the population of alcohol-consuming population as whole (We have bet a minimum-priced pint on this).

A second complaint about minimum pricing is that overall alcohol consumption is already falling in the UK, so there is no real problem for the government to solve. Alcohol consumption is highly skewed though, so total population consumption can drop while problem drinking soars which is what seems to be happening now in the UK.

The third common objection to minimum pricing is that the culture can handle this without government help. Italy for example, has experienced a significant drop in alcohol consumption over recent decades with no effective government intervention (I mean that in an absolute sense, not just compared to the general level of effectiveness we associate with Italian government). Won’t Britons get sick of all the heavy drinking and start to cut back and help their friends and family members cut back through normal cultural evolution?

The most compelling case I ever heard along these lines came from a sitting British politician, so it seems appropriate to tell it here. Continue reading “British Drug and Alcohol Policy: III. What is Minimum Pricing of Alcohol and Will it Reduce Problem Drinking?”

Promoting Public Sector Innovation in a Time of Constrained Budgets

Lately I have been talking to a number of policy makers in the U.S. and in other countries who are facing public sector cuts. Many of them utter words to the effect of “Even if we know a new initiative will work we can’t launch anything during a period of fiscal retrenchment”. A related sentiment was conveyed to me after President Obama’s AIDS Strategy was released. Journalists asked me “What good is a strategy that re-focuses resources on the most affected groups without a major infusion of new spending?”.

Neither comment makes strictly logical sense. Public sector funds should be spent wisely whether the budget is shrinking, stable or growing. A constant frustration of the White House OMB is that everyone is interested in the “B” and few people are interested in the “M”. People come in all day long during budget development season and say “We are spending a hundred million dollars a year to solve problem X and it’s not working, but we have a new idea that will work so we need a ten million dollar increase”. To which the OMBer will typically (and appropriately) respond: “Why not take the money out of the 100 million you spend on ineffective programs, i.e., manage the money you have and not just ask for more?”.

It is axiomatic that any government agency that spends millions or billions of dollars a year is wasting at least some money, either on things that do not work at all or are less effective than other things they could be doing with the same money. A principal challenge of public sector management is cutting ineffective programs even when the money will stay in the agency and can be re-directed to programs that are effective. This situation dramatically decreases opportunities to innovate. Indeed, innovation becomes one of those luxuries a public sector manager can consider only every 3 or 5 or 10 years when the budget looks unusually good.

In my observation, which I hope RBCers will supplement with their own, at least three forces impede the replacement of less effective programs with more effective ones. Continue reading “Promoting Public Sector Innovation in a Time of Constrained Budgets”

What Abraham Maslow got Wrong about the Limits of Science and Psychological Knowledge

A group of evolutionary psychologists is proposing a revision to Abraham H. Maslow’s famous hierarchy of needs pyramid, replacing self-actualization at the top with parenting. They will continue, quite sensibly, to be put physical needs at the base of the pyramid, reflecting Maslow’s insight that when these are not met, human beings tend to think about little else.

The revisionists want to place parenting at the top because they see no evolutionary purpose to self-actualization. There is a better reason to be dubious of a psychology theory that tries to assign scientific validation or superiority to self-actualization or any other subjective values concerning how people should live.

The best sense I can give of how influential Maslow was in psychology in the 1960s and 1970s is that the eminent George Albee ran against him in 1968 for American Psychological Association president and lost by a landslide, leading George to say “My wife and mother voted for Maslow”. Maslow was influential because he was very smart, wrote well, and had many good ideas. But he was also influential because his theory told many of the cultural elites of the era that they were objectively more mental healthy and more psychologically developed than were their opponents. Flattering poppycock, and also dangerously undemocratic. Continue reading “What Abraham Maslow got Wrong about the Limits of Science and Psychological Knowledge”

Optimism about the mental health of the Iraqi people

The news service of the United Nations Office of Coordination of Humanitarian Affairs has a report out on psychological trauma among Iraqis. What Iraqis have gone through over the past 40 years rivals the suffering of any other people in the world, but overall, things actually look less bleak in terms of Iraq’s mental health than they did a few years ago.

The mental health survey numbers in the UN account are shocking if you compare them to rates in peaceful countries, but among nations that have experienced war and terrorism (e.g., Lebanon, Rwanda) they are actually relatively low. When I predicted an epidemic of PTSD a few years ago I may have underestimated some important stress buffering factors in the country: Families are close knit, religious faith is widespread, and while addiction is becoming much more prevalent, a significant portion of the population uses no alcohol or drugs at all.

The UN news report mentions the expansion of psychological therapy services in Iraq, which is a major achievement for the Iraqis and was facilitated by the support of the U.S. Substance Abuse and Mental Health Services Administration, the U.K. National Health Service and Royal College of Psychiatry and the International Medical Corps. Another critical factor has been the leadership of Dr. Salih Mahdi Motlab al-Hasnawi, who is a rare creature in the world of health policy: A national Health Minister with a specialization in psychiatry. Continue reading “Optimism about the mental health of the Iraqi people”

24/7 Sobriety is Saving Lives in South Dakota: Why Not Everywhere Else?

Mark and I have a short piece in Newsweek praising an innovative anti-drunk driving program in South Dakota, which has reduced road deaths and may also be reducing the prison population. You can learn more about the program from the National Partnership on Alcohol Misuse and Crime; what I want to add here are the on-the-ground observations I made as I spent 3 days this week watching it in action.

For a criminal justice program, 24/7 Sobriety is remarkably respectful of offenders. I spent one morning at a breath test station and watched dozens of people convicted of DUI come in, get breathalyzed and then move along, each taking no more than a minute or two. The staff members were friendly, greeting each person by name and wishing each a good day. The building looked like a credit union. Because there were no uniformed officers, cell bars or guns visible, offenders with aversion to law enforcement would not have any instinctive ambivalence about coming in. The offenders also had some comaraderie among themselves, expressing pleasantries as they saw other offenders they knew in the testing station.

The atmosphere was, in short, completely different than what I had seen in many correctional programs I have visited over my career. Antagonistic interactions with and degradation of people who have been convicted of crimes are not uncommon in corrections. This is bad in itself, and also generates rage and oppositional attitudes in offenders that may be expressed destructively at the time or later when they are no longer under supervision. 24/7 Sobriety has a completely different tone, and that’s good for offenders and also for everyone else.

The visit also spurred some thoughts about the diffusion of innovation. Continue reading “24/7 Sobriety is Saving Lives in South Dakota: Why Not Everywhere Else?”

How the DMV Undermines Democracy

“She was a fat, resentful woman. The kind who is always behind the counter at the DMV when you need to renew your registration”

–P.J. O’Rourke, A Parliament of Whores

“There are days when we don’t let the line move at all.”

–Patty and Selma, The Simpsons

I generally ignore the protesters with the “Obama-is-a-Radical-Muslim-with-a-crazy-Baptist-preacher-in-Chicago” and “Get government out of Medicare” signs when I walked from the Metro station to my office in Washington D.C. But the day I had to register my car at the Virginia DMV, I saw a method to at least one protester’s madness. He set up a table about 300 yards away and around two building corners from the front door of the DMV. Continue reading “How the DMV Undermines Democracy”