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Focus on the families

Measuring alcohol-related harm; politics and science

Does it matter if ‘addiction is a brain disease’?

Focus on the families

This hot topic explores interventions with families affected by substance use, and includes issues as varied and important as the (lack of) recognition that relatives might also be ‘carers’, why we should think of family members as individuals needing support as well as parts of a family unit needing support, and the dilemma for service providers about how to safely and effectively deal with conflict in families. Documents retrieved by this search focus primarily on the welfare of the families themselves, but will include some on family therapies promoting the welfare of the problem user; another search focuses on this topic instead.

The ‘forgotten’ carers

Given the nature of addiction, it is not uncommon for the family members of a person with substance use problems to also fulfil a ‘caring’ role, adding another layer to the difficulties they face. The Care Act 2014 limited the definition of a carer to adults, but the Carers Trust points out that there are an estimated 700,000 young people under the age of 18 in the UK also helping to “look after someone in their family, or a friend, who is ill, disabled or misuses drugs or alcohol”.

UK clinical guidelines

The UK National Institute for Health and Care Excellence (NICE) recommends that where the needs of families and carers of people who misuse drugs have been identified, staff should:
• offer guided self-help, typically consisting of a single session with the provision of written material;
• provide information about, and facilitate contact with, support groups, such as self-help groups specifically focused on addressing families’ and carers’ needs.

Also, where the families of people who misuse drugs have not benefited, or are not likely to benefit, from guided self-help and/or support groups and continue to have significant problems, staff should consider offering individual family meetings. These should:
• provide information and education about drug misuse;
• help to identify sources of stress related to drug misuse;
• explore and promote effective coping behaviours;
• normally consist of at least five weekly sessions.

Caring is often an invisible and unpaid activity. When marginalised and stigmatised problems are added to the mix, or are the source of the caring work, this can compound the invisibility – even to the point where family members don’t perceive themselves as carers. The high esteem in which carers of a relative with a disability or chronic health condition such as diabetes are held doesn’t always translate to substance use problems, which tend to be viewed through a moral lens.

There is growing evidence that supporting the relatives of people affected by substance use can bring huge benefits to the whole family, as well as potential cost-savings to services. Interventions targeting family members’ own needs can result in increased resilience, life satisfaction and relationship satisfaction, decreased stress and distress, and benefits for the people around them, including children.

Despite this promising evidence, there has historically been a lack of recognition of family members’ support needs (in particular, those of adult family members) in drug and alcohol policy and guidance. In 2012, the UK Drug Policy Commission’s report The Forgotten Carers highlighted this gap, and recommended more assertive promotion of help for adult relatives in primary care settings, and routine assessment of their needs when relatives with substance use problems engage with treatment.

The 2017 Drug Strategy acknowledged the impact drug use can have on families, but focused family-based solutions on the prevention and treatment of drug use – highlighting the need to target support at those most at risk of “misusing drugs”, such as vulnerable young people, vulnerable families, and victims and perpetrators of domestic abuse, and the need for vulnerable families to be supported to break inter-generational pathways to dependence. Beyond this the strategy advised that “local areas should ensure that the support needs of families and carers affected by drug misuse are appropriately met”, but did not specify or direct how. Whether in any event this strategy is the right context in which to recognise and respond to family welfare is debateable, sitting as it does within the remit of the Home Office rather than health or social care policy teams.

Clinical guidelines from the UK’s official health advisers (view a summary here, commentary here, and specific implications for families above) recommend that as well as explaining options for abstinence-oriented, maintenance-oriented and harm-reduction interventions to clients with substance use problems, staff should discuss with them whether to involve their families and carers in their assessment and treatment plans, ensuring that the service user’s right to confidentiality is respected.

Both an untapped treatment resource and a group needing support


Five levels of response to family members, showing “range of flexible services of different intensities”

At least two separate (but related) support needs are evident among the relatives, partners, and friends of people with substance use problems: firstly, wanting to contribute to the treatment of their loved one; and secondly, needing help to deal with their own stress. According to reviews of family-based drug treatment, these two needs are reflected in treatment approaches – namely by working with family members to facilitate the entry and engagement of the user in treatment, interventions for family members in their own rights, and treatment based around joint working with family members and the substance user (1 2).

In 2009 the UK Drug Policy Commission designated five different levels of response to family members affected by drug problems: responding to family members in non-specialist settings; assessment; services specifically focused on providing help and support to family members in their own rights; responding to family members delivered as part of services for drug users; and intensive family-based therapeutic interventions ( image).

These levels weren’t intended to depict a hierarchy of provision (ie, level 5 is not ‘better’ than level 4), but rather the range of interventions that should be available in order to meet the differing needs of family members. The key principle was that “there should be a range of flexible services of different intensities that can respond to the varied and complex needs of families affected by drug problems” (emphasis added). Three years later, a follow-up report contrasted the recommended levels of provision against actual provision, as described by 43 stakeholders, from five regions in England. Unfold supplementary text Click here to see the comparison.

Two British studies explored the feasibility of a short intervention with relatives in a primary care setting, raising some doubts about how successfully an intervention of this kind could be rolled out across the UK. The first study gathered the views of 27 patients who had participated in up to five sessions with a primary health care worker. These patients reported that after the intervention they relied less on unhealthy coping strategies and felt physically and psychologically better. This study evolved into a second larger study involving 136 local doctor’s surgeries in England. Patients were allocated to one of two groups this time, one offering five sessions, and the other offering a single session. There were no significant differences between the groups. Instead, across both groups there were significant improvements on all the assessed outcomes. However, it proved very challenging to engage primary health care workers and local doctor’s surgeries, despite the offer of funding. It could be that incorporating substance-related questions within general health screening for the adult relatives of people with substance use problems may be a more acceptable strategy in primary care.

Avoiding harm and bolstering resilience in families with children

The studies described above are rare examples of interventions that consider how substance use might be affecting adults around the person with a drug or alcohol problem, and what support family members and friends might need in their own rights. Most studies in the field of family interventions have focused on protecting the welfare of children and families where the parent or carer has a substance use problem.

Scottish approaches for working with children, young people and families where problematic alcohol and/or drug use is a factor advocate ensuring that child protection, recovery and wider family support concerns are brought together within a coordinated approach to giving the best support possible. In 2012, Getting Our Priorities Right outlined practice guidance for child and adult service practitioners working with children, young people and families where problematic substance use is a factor. Key principles were a ‘whole family’ approach for assessing need and early intervention activities – “working together effectively at the earliest stages to help children and families and not waiting for crises – or tragedies – to occur”.

The Australian Institute of Family Studies has reviewed literature on the outcomes of children raised in families with multiple problems including parental substance misuse. Their review notes the ‘risk factors’ for children living in families affected by substance use, but adds that interventions which aim to build on parental strengths generate ‘protective factors’ which mitigate those risks. It argues that another crucial consideration in treatment approaches should be the wider social environment, in which poor housing, unemployment and social isolation influence outcomes for children. They conclude by saying that “families will fare best when they are engaged in the process of treatment, feel a part of the treatment, have a commitment to the treatment and hold the view that they are working with the service to achieve common goals”.

Engagement in treatment was explored in a reflection on a pilot study in Scotland. Though contact might be initiated against parents’ wishes and proactive monitoring is essential, the authors advised that successful early intervention with families is reliant on generating their voluntary participation, and requires close attention to means of facilitating positive and motivated parental engagement. Interventions with families have typically been characterised by the central aim of monitoring child welfare. Fearful of the consequences of the ‘enquiring gaze’ of social services, parents may resist meaningful engagement. This particular study explored resistance in the context of six families affected by substance use, defined as in need of supportive intervention. The authors suggested that resistance could be overcome by improving the way services communicate with families, and “exploration of the possibility of putting some distance between the offer of support and an often all too close link with the threat of punitive action”.

The Australian National Council on Drugs (ANCD) commissioned a review of policy in relation to child- and family-sensitive practice in Australia. The report referenced a workforce development guide, describing child- and family-sensitive practice as “raising awareness of the impact of substance abuse upon families, addressing the needs of families, and seeing the family – rather than an individual adult or child – as the unit of intervention”.

Option 2 was a crisis intervention service, funded by the Welsh Assembly, designed to view the family as the unit of the intervention. Specifically, it focused on working with high-risk families, where there were serious child protection concerns related to parental substance use. The intervention lasted four to six weeks, and used a combination of motivational interviewing and solution-focused counselling styles. An early evaluation of the service found that families liked the service and that it reduced the need for children to enter care, generating significant cost-savings for local authorities. A subsequent evaluation confirmed that this model significantly reduces the need for children to enter care, is likely to generate very significant cost-savings for local authorities and other social care, health and criminal justice agencies, appears to be an effective way of engaging and helping parents with serious drug and alcohol problems to significantly reduce their drug or alcohol use, and overall, improved family wellbeing and parental welfare.

Multi-pronged services to meet multiple needs

Speaking to the need for integrated or coordinated services, parental profiles from UK family drug and alcohol court research reinforce the picture found in other studies of the many difficulties parents experience in addition to substance use, especially the so-called ‘toxic trio’ of substance misuse, mental health issues (37% of family drug and alcohol court cases and 40% in ordinary proceedings) and domestic abuse (71% and 64%).

Responding to the need for multi-pronged services to meet multiple needs, programmes have been developed which integrate addiction treatment with on-site pregnancy, parenting, or child-related services, typically providing individual addiction treatment, maternal mental health services, trauma treatment, parenting education and counselling, life skills training, prenatal education, medical and nutrition services, education and employment assistance, childcare, social services, and aftercare. One pilot study trialled residential substance use treatment integrated with a brief (10 sessions) yet intensive attachment-based parenting programme for new mothers. Subsequent observations of parent and child together found more supportive and sensitive parenting behaviours.

In a criminal justice context, when asked to describe the typical characteristics of men and women coming before them for sentencing, 14 magistrates and judges in the North of England said that they tended to be drug users, and also tended to lack qualifications, have poor or non-existent work records and unstable family lives. They also observed differences along gendered lines:

“… there’s all the issues related to their … children and their relationships with often violent or difficult male partners, that makes them a very vulnerable and very difficult group to deal with. It’s difficult to decide sometimes, because you don’t know whether it’s mental health that is the root, which is being disguised by alcohol, drug abuse, or both. Or whether, actually, the alcohol or drug abuse has triggered the mental health issues. And so often, you get this multi-layered sort of difficulty, that you’ve got somehow to deal with within a fairly … particularly in the traditional system … constrained sentencing regime that we have; very difficult to do.”

In their experience women constituted a minority of defendants, and their offending tended to be less diverse and generally less serious – public order, theft, and drug possession were mentioned most often. Women’s problems were also seen as more inter-related and hard to disentangle – for example, frequently having sole or main responsibility for children and other dependents (eg, elderly relatives), being victims of domestic abuse, suffering from mental illness, and having histories of abuse as children.

Safely keeping families together

One of the major barriers to coming forward for treatment is the stigma, shame, and guilt around having a problem with drink or drugs – something which may be experienced more acutely among parents. For women in particular, who more often have primary caring responsibilities, the concern is not just about how they will be perceived as mothers, but that once they’ve disclosed “they will be deemed an unfit mother and lose custody of their children”.

The family drug and alcohol court model recognises the difficulty for parents in separating their substance use and recovery from their caring responsibilities and desire to keep their families together. Unlike traditional family courts, they have a team of experts from substance use and child welfare, aligning the treatment goals and philosophies of both sectors. There are currently nine teams in the UK, working in 12 courts and servicing 15 local authorities in London, Gloucestershire, Milton Keynes and Buckinghamshire, East Sussex, Coventry, South West Peninsula (Devon, Plymouth and Torbay), Kent and Medway, Southampton, and Leeds.

A pilot study in London suggested that compared to ordinary care proceedings, family drug and alcohol courts produce better parental and child outcomes at a lower cost. Five years later, the family drug and alcohol court remained more successful than ordinary services in helping parents to sustain recovery, in minimising risk, and in keeping families together. What the family drug and alcohol court couldn’t do, however, was remove risks entirely for families further down the line. Written information collected from case files in relation to ‘life events’ highlighted the continued challenges faced by families. The two years after proceedings was the period of maximum risk, indicating that support during this period could for many parents help prevent problems accumulating and taking hold.

The above evaluations focused on families going through care proceedings between 2008 and 2012. Since then a number of changes have come into effect. Perhaps most pertinent to the family drug and alcohol court was the introduction of a 26-week time limit for completing care and supervision cases (under the Children and Families Act 2014). The implications were addressed in a 2014 report, which referenced professionals’ concerns about the “extent to which this will help or hinder attempts to improve outcomes for children affected by parental substance misuse” – that it will, in theory, “reduce the time available to test parents’ motivation and ability to control their problematic drinking or drug use, through a therapeutic intervention overseen by the court”.

Another family-centred approach, this time from the United States, aimed to support mothers facing loss of custody to get to the point where they could be reunited with their children. The Engaging Moms Program helped them to comply with court orders, engage with substance use treatment and develop their parenting skills. A small-scale study compared its effectiveness with that of traditional case management (coordination of services). In comparison, more mothers in the Engaging Moms group retained their parental rights and completed the drug court programme. Furthermore, at the three-month follow-up participants in Engaging Moms reported significantly stronger therapeutic relationships with their counsellors, a factor known to facilitate ongoing engagement with treatment.

A strong therapeutic relationship is often cited as an important platform for successful interventions, as is a programme tailored to the needs of the client. A US-focused progress review advocated integration at the service delivery level through a comprehensive assessment which documents all the client’s co-occurring health and social problems, and which systematically matches service needs to problems in the context of a positive client-provider relationship.

Few systematic reviews have been conducted to assess whether integrated services improve parenting outcomes, but the limited evidence does suggest integrated services may generate small improvements in parenting. Though by no means a spectacular result, among high-risk families this may have the knock-on impact of reducing the need for foster care and improving the wellbeing of children.

Turning around ‘troubled families’

Following riots in England in 2011 triggered by the death of Mark Duggan in Tottenham in London, a government initiative called the Troubled Families Programme was announced. Its goal was to ‘turn around’ the lives of the 120,000 most ‘troubled families’ in England by May 2015. The initial definition of a ‘troubled family’ excluded many of the deeply embedded social issues described above, instead focusing on addressing youth crime or anti-social behaviour, children regularly truanting or not in school, adults on out-of-work benefits, and families imposing high costs on the taxpayer.

The scope of the programme was later expanded to include families having at least two of the following problems:
• parents or children involved in crime or anti-social behaviour;
• children who are not attending school regularly;
• children who need help; that is children of all ages, who need help, are identified as in need or are subject to a child protection plan;
• adults out of work or at risk of financial exclusion or young people at risk of worklessness;
• families affected by domestic violence or abuse;
• parents or children with a range of physical and mental health problems.

These developments occurred “only months after an evaluation was commissioned, [and] long before any findings were published”. A briefing paper from the Centre for Crime and Justice Studies observed that the lack of evidence informing the upscaling and evolution of the programme was evident early on, and concluded that “the [Troubled Families Programme] itself would benefit from the same kind of ‘persistent, assertive and challenging’ intervention it prescribes for disadvantaged families.”

An interim report from the national evaluation in 2014 gave insight into the characteristics of families actually reached by the Troubled Families Programme, showing that crime, anti-social behaviour and substance abuse, even at fairly low levels, represented only small minorities of official ‘troubled families’ – 93% of families, for example, had no adults clinically diagnosed as being dependent on alcohol, and 93% had no adults with a clinical diagnosis of dependence on non-prescription drugs.

For the current Conservative Government, the Troubled Families Programme is an important conduit for reducing “worklessness”. In the April 2017 policy paper Improving lives: Helping workless families, drug and alcohol problems are described as “closely associated with worklessness”:

“…research shows higher rates [of substance use problems] in unemployed people compared to employed people, and that substance misuse increases the risk of unemployment, and decreases the chances of employment…”

Another Effectiveness Bank hot topic has examined the prominence of unemployment in the population of problem substance users, and the many barriers to work. It also raised questions about how realistic competitive employment is for people whose lifestyles have revolved around obtaining drugs (rather than honing their CVs) and perhaps gaining a criminal record in the process, at what point in a person’s journey the goal of employment should be on the table, if employment is predominantly a ‘means to an end’ of achieving recovery and reintegration, and whether it would be more fruitful to look beyond the binary outcomes of ‘being in work’ and ‘not being in work’. Furthermore, it prompted reflection on the impact of using potentially stigmatising language like the official government term “worklessness” – which suggests that not being in work (or at least not being in work recognised by the state) is a condition of the individual or family – when referring to people who probably not only have personal barriers to work, but also institutional and structural barriers. For many, unemployment is one of a multitude of factors that compose social exclusion, and have the cumulative effect of obstructing their ability to participate fully in society (including finding gainful employment).

Substance use-related family conflict v. domestic abuse

Disagreement and conflict is common in families, and may be exacerbated in those coping with problem substance use. But for Adfam, a UK charity working to improve life for families affected by drugs and alcohol, it is important for professionals to know and feel confident enough to distinguish between family conflict and domestic abuse, and to be aware of the risks of assuming either will automatically be alleviated when substance use problems are resolved.

While there is a strong association between domestic abuse and substance use, and alcohol in particular is thought to escalate existing conflicts, the evidence shows that not all people attending alcohol treatment are abusive, nor do most domestic abuse incidents take place when the perpetrator is drinking or using drugs. So, it is not the case that there is a simple causal relationship between substance use and domestic abuse. Substance use is better understood as a ‘disinhibitor’ which gives a perpetrator the belief that they will not be held accountable or responsible for their behaviour. Treating this as “responsible disinhibition” enables professionals to recognise that the perpetrator may experience some level of disinhibition as an effect of consuming alcohol or other substances, while still holding them responsible for their actions.

In some cases, both partners might claim to be victims, or it may be apparent that both have used violence against each other. This does not necessarily mean that the violence is mutual – of equal significance on both sides – or that the causes and contexts are the same (eg, related to both partners drinking or using drugs). In circumstances where there may be bi-directional violence, it is important to think about context, intent, and effect – for example, did the person use violence to induce fear or to protect themselves, and what effect did the violence have?

Against Violence and Abuse (AVA), a national organisation working to end all forms of violence against women and girls, urges professionals ‘not to make substance use an excuse’, writing that in addressing perpetrators of domestic abuse who use drugs or drink problematically, it is not sufficient to only address their substance use hoping that abuse will subsequently cease. This would not, for example, “address the many social and cultural factors such as perpetrator’s sense of entitlement and attitudes”, or “the complex dynamics of power and control” that often underpin domestic violence.

A toolkit and complementary eLearning programme produced by AVA were designed for professionals working with clients who have issues spanning substance use, domestic and sexual violence, and mental ill-health, and aimed to uncomplicate “complicated matters” by raising awareness about “how the three issues interlink and reflecting on the most effective ways to engage with individuals and families who are affected by these issues”.

Directing readers to “Think family”, AVA says:

“A survivor’s parenting abilities may be affected by all three issues, so her children’s safety and well-being must be taken into consideration. The greatest risk of harm, however, comes from the perpetrator. Any non-abusing parent should be supported to improve their skills and confidence in looking after their children, and not blamed for ‘failing to keep the perpetrator away’.”

Admittedly, ‘thinking family’ is not as easy as it sounds for organisations trying on the one hand to keep families together or to treat the family as the ‘unit’ of the intervention, and on the other to ensure services are safe and conducive to vulnerable people making disclosures or talking about domestic abuse.

As Adfam writes, “families are often the unheard and unseen victims when a loved one uses drugs or alcohol, and on top of the physical and psychological strains, they must struggle to get the support they need … all the while grappling with the stigma and shame from wider society”.

Run this search for more on protecting and improving life for the families of problem substance users, or instead this search for information on interventions with families aimed at helping a relative with substance use problems. Also perhaps of interest is a collection constructed for Alcohol Awareness Week 2017 on the theme of ‘Alcohol and Families’, embracing two major roles for the families of problem drinkers: as recipients of support and therapy to promote their own welfare, and as therapeutic agents engaged in promoting the drinker’s welfare through family therapy or less formal involvement in treatment.

Thanks for their comments on the original entry to Richard Velleman of the University of Bath and Jamie Pennycott of Southend’s Drug and Alcohol Team in England. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 20 December 2017. First uploaded 01 September 2010

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Measuring alcohol-related harm; politics and science

Putting a price on the harm of alcohol helps the government to demand action, authorities to generate a better response to harmful drinking, and campaigners to raise awareness of the harm caused by drinking. It is, in other words, a highly small-p politically salient figure – one which can be calculated in so many different ways and under differing assumptions, that it would be surprising if its malleability were not exploited to political ends.

National UK policy is based on the calculation that each year the adverse consequences of drinking cost society £21 billion. This figure given in the UK alcohol strategy was unpacked in the government’s response to the consultation on the strategy: alcohol-related crime cost £11 billion in England and Wales at 2010/11 prices; at 2009/10 prices, across the United Kingdom lost productivity cost £7.3 billion; and the treatment of alcohol-related illness cost the National Health Service £3.5 billion – estimates repeated by the National Institute for Health and Care Excellence (NICE) in its quality standards on preventing harmful alcohol use chart. The figures include some valuation of the emotional impact of alcohol-related crime (nearly £4.7 million) but not of the value to the drinkers of their diminished quality and lost years of life due to drinking or the emotional impacts on their family and other associates. They are an attempt to quantify the third-party and wider societal impacts of a drinker’s drinking, on the assumption that the drinker themself is prepared to pay in money and some loss of life and quality of life for the pleasure they gain from drinking, and therefore suffers no net loss of value.

The variety and history of such estimates has been handily compiled by the Institute of Alcohol Studies. They note that the £21 billion estimate has its roots in a report published in 2003 by the UK government’s Cabinet Office, which estimated that in 2000/01, alcohol-related death, illness and crime cost England about £20 billion. An update of the costs to the NHS included in that estimate raised it to £2.7 billion at 2006/7 prices. In 2010 NICE limited its calculations to costs associated with healthcare, crime, antisocial behaviour and employee absenteeism, calculating an annual total for England of £12.6 billion. In that report inflation was estimated by 2008/09 have raised the costs to the NHS to £2.9 billion. At 2006/7 rates, alcohol was estimated to have cost Scotland £2.25 billion, of which the greatest part was due to lost and diminished productivity including unemployment and years of work lost due to premature death. For the UK as whole, in 2005/06 costs borne by the NHS were estimated at about £3 billion. The same study funded by the British Heart Foundation calculated alcohol-related deaths at 31,000 in 2005 and that in 2002, one in ten disability-adjusted life years had been lost to alcohol. Liver disease is a major component, in England and Wales predicted to lead to a cumulative total of 143,000 deaths over the 20 years from 2010, during which year the number was 6317.

Impacts on health and the costs of responding to those impacts are in some estimates overshadowed by the consequentially diminished size and productivity of the workforce. Across four high-income countries, these accounted for nearly three-quarters of the external costs (ie, not those affecting the drinker themself) imposed by drinking. Scotland was one of the four, where in 2001/02 productivity losses were calculated to have accounted for 58% of costs. In the UK as a whole, understanding of these impacts is limited by a lack of data about the effects of drinking on ‘presenteeism’ (reduced productivity at work), absenteeism, unemployment, and premature mortality among the workforce, as well as the impact on the people and families involved. The most recent and relevant UK government estimate ( above) was £7.3 billion across the UK in 2009/10 out of an estimated “total cost to society” of £21 billion. The largest element in the £7.3 billion was lost output due to premature death; missing was the costs of reduced efficiency at work.

Depends where you look

Due to inequalities across different areas and social groups, the weight of the burden of alcohol-related harm depends to a large degree on where you look and who you look at. Alcohol-related death rates, for example, have consistently been higher in Scotland than in England, though the rate in Scotland has fallen sharply since the mid-2000s for both men and women, while the rate in England has been flat following a period of steady growth since the early 1990s.

In 2016, 7327 deaths were recorded in the UK as wholly attributable to and a direct consequence of drinking, an age-standardised rate of 11.7 deaths per 100,000 of the population. At 16.2 per 100,000, the death rate for men was more than double that for women, and at 40.3 reached its peak among 60–74-year-old men. Across both sexes, in 2016 the death rate peaked at 29.3 among 60–64-year-olds, a phenomenon seen only since 2015; in 2001 the peak age-band was 10 years younger. Among the countries of the UK Scotland remained the most affected, with death rates of about 30 and 12 per 100,000 among men and women respectively. At about 22 for men and 10 or 12 for women, England’s North East region and Northern Ireland were not far behind, while at around 10–12 for men and 5 for women, rates in London and the South East and East of England were half those of the North East.

Regional disparities are tied up with and seem partly to parallel disparities in socioeconomic deprivation. In 2016, the rate of alcohol-specific deaths among males in the most deprived fifth of areas of England was about 30 per 100,000 and for women about 13, respectively 4.5 and 3.3 times higher than in the least deprived fifth of areas. Hospital admissions in which alcohol contributed to the primary reason for the admission follow a similar pattern to deaths, being most frequent among people living in the most deprived areas of England and progressively less frequent among those in better-off areas. In 2015/16 the disparity ranged from 790 admissions per 100,000 in the most deprived tenth of areas to 493 in the least deprived tenth.

Regional and socioeconomic disparities also partly parallel the prevalence of hazardous or harmful drinking, which according to household surveys conducted in England in 2014 and 2016 is most common in the North East and less common in the south of the country. In this study risk was defined in a way which conflated overall consumption and high-volume single-occasion drinking and their consequences. Part of the reason for greater levels of alcohol-related harm in northern regions may be that drinking there is more often single-occasion ‘bingeing’, while in the south near-daily drinking is more common. Strikingly, among adults who had drunk in the past week, health surveys in 2011–2013 found that the proportion of men who during that period had drunk twice or more of the recommended intake on a single occasion was at its height in the North East of England, while the same region had the lowest proportion of men who had drank on at least six of the seven days. The more deprived the area in which the respondent lived, the more likely they were to drink heavily at a sitting, while there was an opposing trend for near-daily drinking.

Disparities in the harmful consequences of drinking can be translated into monetary values and summed, offering a single total on which to compare regions and demographic groups. An example is a study which calculated the overall cost of alcohol-related ill-health and deaths in Scotland at £7457 million in 2009/10. Based on the components which could be broken-down by level of deprivation, the burden of alcohol-related harm was greatest among deprived groups, with 40% of the total cost coming from the 20% most deprived areas. In these areas the mid-point estimate of costs was £7240 million compared to £496 million in the least deprived fifth of areas. The largest share of costs (79%) derived from “intangible” components such as pain and suffering among the drinkers and those they affect, which do not have a market price, but do have a value, assessed by how much in a hypothetical situation people say they would be willing to pay to avoid them.

The ‘alcohol harm paradox’

Greater alcohol-related harm associated with greater deprivation forms one arm of the so-called ‘alcohol harm paradox’. The other arm is the association between deprivation and lower alcohol consumption. Together these form the ‘paradox’ – the observation that people of lower socioeconomic status drink less than their more favoured peers, yet experience greater alcohol-related problems. Its importance in the present context is that it demonstrates that harm from drinking cannot simply be assumed to correlate with the amount drunk, but must be directly assessed.

In England, proportionately fewer lower-status adults drink at all. Among those who do, lower status is associated with drinking less according to the AUDIT alcohol screening questionnaire’s consumption measures, but also with greater harm and dependence as assessed by the same questionnaire – a disjunction mainly due to the concentration of harm among the most disadvantaged in society. In turn, this may partly be explained by the fact that while in England people of low socioeconomic status are less likely to exceed recommended safer drinking limits, they are more likely to drink at extreme levels. The differences are large; for example, adults living in the fifth most deprived neighbourhoods are over twice as likely as those in the top fifth to drink 680g of alcohol or more a week for women and 880g or more for men. Also, the more deprived the area in which someone lives and (for men) the lower their occupational status, the more likely they are to drink a large amount at a single sitting rather than drinking smaller amounts near-daily.

Also possibly accounting for the alcohol harm paradox is the clustering of other risk factors, aggravating the effects of drinking. In a phone survey of adults in England (which managed to interview only about a fifth of those phoned), the most deprived two-fifths of respondents were over ten times as likely as their better-off counterparts to combine drinking above recommended levels with smoking, excess weight, and either poor diet or lack of exercise. In contrast, among risky drinkers the better-off three-fifths were over twice as likely to be free of these other risk factors as the most deprived two-fifths. Concentration of harm among poorer risky drinkers is a key rationale for effectively pricing them out of excessive drinking by setting a high minimum price for a unit of alcohol, helping to redress the health inequality entailed in the alcohol harm paradox.

Ageing caseload raises profile of health problems

To the challenges of treating dependence are increasingly being added the challenges of dealing with the aftermath of many years of substance use and the diseases of age.

The typical age of problem drinkers in treatment (including those also using other drugs) has been increasing. From 27% of the caseload in 2005/06 and 32% in 2009/10, by 2015/16 the over 44s constituted 42% of all drinkers in treatment, increasing in numbers from 46,996 in 2009/10 to 60,299 in 2015/16. In contrast, over the same period numbers aged below 35 fell from 52,706 to 39,625.

The caseload whose sole problem is drinking are older still. In 2014/15 and 2015/16 – the only years for which figures have been published – most were 45 or over, 52% and 53% respectively.

Public Health England has warned that many of these people will have been drinking at high-risk levels for some time and are likely to be experiencing illnesses such as liver disease and high blood pressure.

Comorbidity of drinking and other conditions is also an increasing feature of the caseload of problem drinkers in treatment in England – not only because the typical age of those in treatment has been rising, but because many older people will have been drinking at high-risk levels for some time and are likely to be experiencing illnesses such as liver disease and high blood pressure panel. Aging of the treatment caseload parallels that of the population drinking at harmful and dependent levels, shrinking as a proportion of the under 35s but increasing among those aged 45 and over.

What to count, what not to count

Among the shifting and uncertain sands of alcohol-cost calculations, some components such as alcohol-related liver-disease deaths seem relatively solid, but others are subject to assumptions and decisions about what to include and what to record which if varied would hugely change the estimates. The uncertainty is nowhere greater than when analysts attempt to attach £ signs to the impacts of drinking. In 2009 a review found 20 such studies which varied substantially in their methodologies and in their estimates, resulting for example in an implausibly large tenfold gap between estimates of the per capita costs imposed on the populations of Portugal and the USA.

Calculating costs alone is only part of the equation – drinking happens because the drinkers at least feel they get some benefits. When an attempt is made to calculate net costs (ie, benefits minus costs) what is missing from the calculations becomes even more critical than when costs alone are calculated. Notably, how much drinkers value the pleasure they get from drinking and its social roles are typically omitted.

A prominent alcohol expert has argued that estimates of the net cost imposed on society by drinking have often been grossly inflated because (among other things) they assume that hazardous drinking must be irrational consumption, that crime benefits no one, that drinking has no social, psychological or indirect business benefits, and that productivity losses are not counter-balanced by benefits elsewhere and by other workers taking over the jobs of the alcohol-impaired, eventually balancing the original job loss with one more unemployed person gaining work. Critiques from some of the world’s leading alcohol researchers broadly supported the thrust of the argument.

What counts in setting alcohol taxes?

Illustrative of the political salience of what we choose to count is the relatively high-profile spat between the free-market think-tank the Institute of Economic Affairs and the Institute of Alcohol Studies, whose focus is on promoting effective prevention of alcohol-related harm. In 2015 a report from the Institute of Economic Affairs had reconstructed the £21 billion cost estimate for England originating from the Cabinet Office to include only direct costs to government and ultimately the taxpayer. Though some new costs were added (welfare payments), the figure amounted to just £3.9 billion in 2015 prices: £1954 million to treat alcohol-related injuries and ill health, £1626 million to tackle alcohol-related crime, and £289 million paid in benefits to those unable to work as a result of alcohol-related mental or physical health problems. It was an attempt to confine the debate on alcohol taxation to the balance between costs and revenue to the state, excluding costs borne by individuals or businesses. The result was an apparent net surplus for the Treasury of £6542 million, supporting the same author’s call for UK alcohol duties to be halved “to make them less regressive and bring them closer in line with duties in other European countries”.

Calculations seen as an attempt to downplay alcohol’s adverse consequences and prevent a bold policy response

The exercise has been portrayed as “an attempt to downplay the importance of alcohol’s adverse societal consequences to reduce the possibility of a bold policy response and limit participation in the policy debate to a narrower range of stakeholders”. Implicitly it rejected use of taxation as a public health measure to curb alcohol-related harm and resultant social costs, limiting it to its fiscal role of recouping direct costs to the state. For alcohol-health campaigners, the dramatic reduction in the cost of drink seemingly justified by the calculations would be a public health disaster, encouraging increased consumption and generating yet greater ill-effects.

The report drew a rejoinder from the Institute of Alcohol Studies, complaining that the Institute of Economic Affairs (IEA) had missed the policy point and even on its own terms, underestimated costs to the state. Especially by excluding the suffering caused by drinking, the IEA had, they said, bypassed the main concerns about drinking: “Most people who are concerned about the level of alcohol harm in the UK are not primarily motivated by a desire to balance the government’s budget. Rather, they are concerned by the damage to public health, crime, social disorder and wider economic costs caused by excessive drinking.”

As well as criticisms of costs being inflated, and calculations failing to take into account the benefits of drinking, many existing estimates have also reportedly either relied on out-of-date data or methodologies – some drawing on data between four and 12 years old, and others ‘refreshing’ figures with the latest available data, but failing to reconsider the procedures for arriving at them. A 2016 paper which examined recent debates about the cost of alcohol to England and Wales contended that “getting better numbers” is critical, but so too is “using numbers better” – in other words, reflecting on what these estimates represent and how we should use them is just as important as improving the data itself.

There is, for example, confusion about what the oft-cited UK Government £21 billion figure actually represents. Sometimes presented as (or presumed to be) the cost to the taxpayer, or the cost to the economy, the £21 billion in fact relates to the “external cost” to society – ie, the “costs not directly borne by the drinker”. This is useful in that it provides a minimum baseline set of costs that almost everybody would agree (in principle) is relevant to public policy. More comprehensive estimates of the total social cost of alcohol, on the other hand, provide a better indication of the scale of the problem, but are unlikely to have clear policy implications, particularly given the difficulties of calculating the corresponding benefits to weigh them against. Among these is an estimate which along with other elements placed a financial value on lives lost or impaired due to health and crime related to drinking, resulting for England in 2006/07 in an estimated total impact on society valued at £52 billion.

In theory, calculations of the net (ie, after accounting for the benefits) costs to society of drinking and other health-impacting lifestyle behaviours would allow policymakers to understand the relative weights they should give to tackling them and the potential for different policy options to reduce these burdens. But in the experience of Colin Angus and colleagues from the University of Sheffield, “decision-makers and stakeholders are rarely interested in the net sum” of costs and benefits. Instead, they tend to be “asked for disaggregated outcomes which are relevant to the interests and remit of individuals or government departments” – the Department of Health primarily interested in costs to the National Health Service and improvements in health outcomes, and the Treasury interested in the impact on tax revenues.

How cataract surgery could be counted as an alcohol admission

Calculations of the burden imposed on the NHS exemplify the shifting-sands nature of some estimates. The main indicator is alcohol-related hospital admissions, in England until 2014 understood to total the eye-catching figure of over a million a year and rising. This figure is not a number of admissions due to drinking, but the sum of the proportions of admissions for various illnesses which research suggests are on average attributable to drinking. For example, someone admitted with an illness on average 25% due to drinking plus someone else with another illness 75% due to drinking would count as one alcohol-related admission.

But the critical fact about this indicator is that an alcohol-related admission (or a fraction of one) can be counted even if the primary reason why the patient came to hospital had nothing to do with drinking. This is because in addition to primary conditions, clinicians can record up to another 19 secondary diagnoses. If any of these are on average alcohol-related, the admission is counted as alcohol-related. The example given by Public Health England is a patient admitted to have a cataract removed from their eye who is also recorded as suffering from alcoholic liver disease. That disease may have little to do with the eye complaint or why the patient was admitted to hospital, but still the admission would be counted as wholly attributable to alcohol.

Not only is this catch-all number far higher than admissions where the primary diagnosis was alcohol-related, it has also been rising much more steeply as hospitals record more and more secondary diagnoses. Inflation in secondary diagnoses is thought to have been at least partly motivated by the fact that it makes patients look more ill, which in turn makes hospitals’ death rates look better. Whatever the motivation, the more secondary diagnoses are recorded, the greater the chance that some will be among those considered on average alcohol-related; there is no need for a clinician to judge whether in this particular case drinking was indeed a factor in the admission. The result can be more recorded ‘alcohol-related admissions’, even if alcohol-related illness rates have actually remained stable and alcohol’s contribution to the hospital workload has remained unchanged.

Hospital admissions attributable to alcohol, England

The impacts of including or excluding secondary diagnoses are huge. Between 2002/03 and 2011/12, the broader indicator more than doubled, rising by nearly 140% from 510,700 to 1,220,300, justifying concerns over alcohol-related harm rapidly escalating to epidemic levels. Stripping out the secondary diagnoses – leaving only those in which drink was thought at least partially responsible for the primary reason for admission – reduced the increase to 41% from 142,000 to 200,900 – not good, but a rise less than a third as steep.

In the end Public Health England decided to continue to publish the broader numbers including secondary diagnoses, but to introduce a narrower measure reliant mainly on primary diagnoses. Additionally the narrower measure includes some secondary diagnoses when rather than the illness itself, the cause of the illness is on average related to drinking, such as an assault causing a facial injury.

The revision made a huge difference to numbers, in 2015/16 resulting in a total of 339,280 alcohol-related admissions compared to 1,119,020 under the broader classification, and reducing the increase since 2003/04 from 127% to 43%. It was this narrower measure which the Department of Health decided to use for the purposes of monitoring public health and assessing the success of health and alcohol policies, slashing the total to a third of the dramatic ‘over a million’ figure and decelerating the steep long-term escalation in admissions under the broader measure. The implication was that the alcohol-related harm these represented also rose far less steeply than was implied by the previous measuring system chart.

As rehearsed by Public Health England, there are good reasons for the new, more restricted indicator of admissions, but there are other benefits too for a government concerned to present its policies as working – particularly, according to an article published in one of Britain’s leading medical journals, the voluntary ‘responsibility deal’ the Department of Health brokered with the alcohol industry in lieu of more intrusive intervention.

What is an alcohol-related death?

Since 2016 the tally of alcohol-related deaths in the UK has been refined down to just those recorded as wholly attributable to and a direct consequence of drinking. The new definition was adopted after consultation and results in a total about 19% lower for men and 25% lower for women because it now excludes deaths partially attributable to drinking. However, trends over time remain similar under both definitions.

What does change is the disparity between the countries of the UK, since the new definition makes least difference to Scotland and Northern Ireland and most to England, widening the gaps between these countries. For example, in 2016 under the old definition the rate in Scotland for men was was 69% greater than in England, but under the new, more restricted definition, 99% greater. Inevitably the new definition underestimates the total number of deaths which would not have happened (or happened so soon) if the deceased had not been drinking, because it excludes deaths partially attributable to alcohol, such as cancers of the mouth, oesophagus and liver, and particularly underestimates this number among those aged 65 and above.

Commenting on the decision to change the definition, The Lancet was most concerned with its potential impact on “efforts to reduce alcohol-related harms” in the UK. “[I]t is not difficult to imagine how it might mitigate urgency” was their main complaint, signifying that as with hospital admissions, how the deaths are counted has small-p political implications.

Reducing the burden

Revisions and critiques which slash (net) alcohol-related harm compared to other estimates are hardly splitting hairs, but despite the uncertainties about its magnitude, there is one certainty: social costs related to drinking are substantial. This burden both reflects and calls in to question the embeddedness of drinking in British society – an embeddedness which generates controversy over how to reduce the burden. In the mix are universal prevention programmes usually targeting all young people in a population or sub-population, price rises, use of licensing powers, widespread screening and brief advice in surgeries and hospitals, and treating the worst cases.

Policy discourse over a minimum unit price for alcohol illustrates how (given a favourable policy climate) understandings of the scale of the alcohol problem elevate the topic on the political agenda, prompting consideration of what previously was unthinkable. In Scotland, adoption of minimum-unit pricing as a key component of a comprehensive alcohol strategy was “partly enabled by a broad set of harms being linked to alcohol and the economic benefits of reducing these being costed”. Estimates of the economic, health and other social costs associated with drinking helped to make these harms visible within policy discussions, and led to a broad range of stakeholders linked to each of these domains (including health professionals, police, the third sector and some industry actors) coming together to advocate for an effective public health policy (1 2) – a process described in another hot topic.

The ‘hardness’ and magnitude of alcohol-related costs is seen as demanding hard and extensive counter-measures

The apparent ‘hardness’ and magnitude of alcohol-related costs is seen as demanding correspondingly hard and extensive counter-measures. In a 2016 evidence review also published as a journal article, Public Health England observed that “stronger overall policy environments” were associated with lower levels of binge drinking and alcohol-related cirrhosis mortality. One gauge of ‘strength’ was consistency of alcohol policies – for example, not undermining the use of warning labels highlighting the risks of alcohol consumption with a unit price that encourages heavy drinking. Overall though, it was relatively inescapable, blanket availability restrictions which found most favour, rather than information, education, exhortation or treatment which the individual is free to ignore or reject: “While these policies vary in their effectiveness and cost-effectiveness, evidence supports those that reduce the affordability of alcohol as the most effective and cost-effective approach to prevention and health improvement.”

After surveying the field, experts convened by Britain’s National Institute for Health and Clinical Excellence (NICE) also prioritised national policy initiatives to restrict alcohol availability by making it less affordable, available in fewer outlets for less time, and promoted less visibly. That uniquely among the nations of the UK, England has no plans to introduce an effectively health-promoting price-raising strategy places the government in that country directly at odds with its own public health advisers.

The studies thrown up by this search address one of the most pressing of Britain’s social and public health issues, but one for which the UK has yet to implement an effective way of reconciling the need to reduce harm with the centrality of drinking in public and private life.

Last revised 31 December 2018. First uploaded 11 January 2010

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Does it matter if ‘addiction is a brain disease’

Alan Leshner, then head of the US National Institute on Drug Abuse (NIDA), was in no doubt: “Addiction Is a Brain Disease, and It Matters,” was the title and claim of his pivotal paper published in 1997. His thesis was that repeated drug use rewires and chemically alters the brain in ways which result in compulsive drug seeking and use – “The addicted brain is distinctly different from the non-addicted brain.” For treatment this was said to matter because “a major goal … must be either to reverse or to compensate for those brain changes … through either medications or behavioural treatments … Elucidation of the biology underlying the metaphorical switch is key to the development of more effective treatments, particularly anti-addiction medications.”

Writing in 2010, years after his tenure at NIDA had ended, Dr Leshner revealed that his depiction and promotion of the model owed much to its public relations utility. He had appreciated its “powerful potential to change the way the public sees addiction”, and sought a resonant metaphor to realise that potential. The solution was to liken changes in brain structure and functioning caused by repeated drug use to a ‘switch’, transforming what was voluntary into compulsively involuntary drugtaking – a metaphor which he admitted was chosen without too much regard to the reality of neural functioning. For him, “Perhaps the most important consequence of conceptualizing addiction as a brain disease was that it explained why one cannot just quit by force of will alone – why treatment is essential.” It was an explanation of a non-fact – most dependent substance users do remit without treatment – but one which might be good for treatment budgets, and he hoped, for the prospective patients.

From the reams written on the roots of addiction, here the focus is on critiques of Leshner’s “chronic, relapsing disease of the brain” model. The other side of the argument – the case for the model – remains well publicised on the web site of the US National Institute on Drug Abuse, while this book offers a comprehensive account of different understandings of the etiology of drug use.

Normal brains in the service of normal citizens

Though US research cash has been the fuel, it has been argued that the brain-disease understanding of addiction “would have never taken hold had it not converged with recovery discourse and become effective at organizing meanings in the popular realm”. In other words, it fit with the recovery agenda, and to the public and their information sources, ‘made sense’ of otherwise contradictory phenomena – like how someone could keep doing something they know is harmful and which they insist they want to stop doing.

The brain reward pathway seen as common to addictions

The brain reward pathway seen as common to addictions

Driven partly by its propaganda value, the model’s prominence within US ‘drug abuse’ circles has been projected internationally by the dominance of US research and perspectives on drug use. Endowing Leshner’s ‘switch’ with evil intent, later NIDA moved on to the ‘highjack’ metaphor adopted from a 1997 US television special on addiction. In 2008 the UK Academy of Medical Sciences followed suit, depicting drugs of abuse as having the power to “‘highjack’ certain brain processes, leading to dependency and addiction in some people”. For these authorities, discovery of a neural reward pathway ( illustration) common to substance and non-substance addictions promised to unify the addictions field, paving the way to correcting “aberrant learning patterns” in the brain generated by regular drug use.

Four years earlier the World Health Organization had published its report, Neuroscience of psychoactive substance use and dependence, proclaiming that “with recent advances in neuroscience, it is clear that dependence is as much a disorder of the brain as any other neurological or psychiatric illness”. A major feature of the report was its appeal to genetic variations to explain why some people’s brains develop these disorders more readily than others.

In these formulations a deviation from normality in behaviour is dramatised as a corresponding deviation from normality in the brain. The treatment task becomes to use the links between these realms to normalise both, generating the productive citizens envisaged by modern understandings of ‘recovery’. According to (free source at time of writing) a historian of drug use and its treatment, these relationships exemplify a broader pattern: “[E]arly twentieth century ‘neurophysiology’ has long been subsumed to the project of achieving good self-governance: personal responsibility, impulse control and appropriate consumption of the ‘right’ drugs”. Since at least the same era, addiction treatment itself has been about restoring citizens to a normal and productive life, not just overcoming dependence – evident when in 1933 US President Roosevelt proclaimed, “In this institution the victims of the opium habit will be restored to usefulness”, and in 1926 when in England the Rolleston committee legitimated the supply of opiates to patients who could lead a “fairly normal and useful life” with the drugs, but not without them.

This at first unlikely alliance between the brain-disease model and re-normalisation formulated as ‘recovery’ lies at the core of the “addiction science” understandings offered to their public by the US National Institute on Drug Abuse: It’s like responding to a TV programme you don’t like by calling a TV repairman “Drugs change the brain in ways that make quitting hard, even for those who want to. Fortunately, researchers … have found treatments that can help people recover from drug addiction and lead productive lives.” For this institution, fundamentally treatment so often fails, not because it has a false understanding of its target, or because it offers insufficient support, but because “Brain changes that occur over time with drug use challenge an addicted person’s self-control and interfere with their ability to resist intense urges to take drugs. This is why drug addiction is also a relapsing disease.” Just how wrong they might be has mockingly been likened to “the guy who responds to a TV program he doesn’t like by calling a TV repairman”.

Justifies the narrowing of treatment

NIDA’s brain disease formula is a prime target for the recently founded interdisciplinary initiative, ‘critical neuroscience’. Introducing this initiative, in 2010 it was argued (free source at time of writing) that the implied natural state of brain functioning which regular drug use subverts is a chimera: there is no “first nature entirely free of human values and interests”. But the implicit acceptance that there is a natural state, aberrations from which generate mental illness and addiction, has real effects. “As soon as such a discourse is dressed up as science – referring to robust facts about our neuronal organization and functional architecture – it is effectively removed from political discussion.”

Another effect is to direct treatment efforts in some directions and away from others. Focus on the level of neural functioning lends itself to a corresponding focus on the chemicals – and even brain surgery and electrical implants – thought to correct faulty brains. De-emphasised along the way are influences such as broader social and environmental conditions, self-management by patients, the treatment setting, and relationships with staff (1 2 3), potentially leading to less effective treatment. More broadly in mental health, it has been argued that “overselling of drug or highly technological therapies induced by commercial propaganda has given the patient the misleading impression that a specific imbalance is the cause of his or her illness [and] leads the clinician to disregard ‘non-specific’ ingredients as optional and uninfluential” – by ‘non-specific’ the author means the common factors underlying effective therapy such as a ‘healing setting’ and therapeutic relationships. The brain-disease model does however excel on another common factor – offering a plausible explanation for the patient’s symptoms.

Yet more directly, the brain-disease model narrows our vision of the roots of addiction. A prominent historian of drug misuse reminds us that the promise of effective treatment opened up by the ‘discovery’ of the neural foundations of addiction has yet to be realised, while this understanding of the foundations closes our eyes to more salient influences: “The prevalence and incidence of drug abuse are largely determined by demographic variables like migration, family stability and birth cohort size, as well as social forces like drug-financed civil wars within failed states, pharmaceutical marketing strategies, bohemian fashion and generational learning (and forgetting) about the dangers of certain drugs.”

The serially failed search for a drug to normalise the cocaine-addicted brain is perhaps the best example of the brain-disease model sending treatment down a blind alley. In 2015 things had not moved on much further than when in 2004 the World Health Organization said treatment advances realistically expected from neuroscience were simply refining existing medications, rooted in advances which long predated modern neurological understandings.

It’s the interpretation that matters

One ‘problem’ brain-focused treatment solutions face is that human beings act not just on the basis of stimuli and feelings, but of their interpretation of those events – interpretations not controllable by drugs or electrical implants. Especially (but not only) in the psychosocial treatment of psychological and behavioural conditions, it is “the meaning that the client gives to the experience of therapy that is important,” not the therapy as such. A tragic example led to the death of a patient in China less than four months after he had enrolled in a trial of deep-brain electrical stimulation for heroin addiction.

The electrical implant worked in the sense that drug use became less pleasurable, but in response the patient doubled his heroin intake. It worked too in that it calmed him and alleviated withdrawal symptoms, but it seems that just gave him the impression he could safely use drugs again. After undergoing implantation on the 1 March 2017, he died of a heroin overdose on the 21 June. The authors cautioned that the psychiatric comorbidity and poor socioeconomic circumstances typical of heroin addicts “poses a significant clinical challenge” for these treatments – in other words, these patients are likely to respond to what seems effective treatment in ways which render it ineffective, like the patients who negate the opiate-blocking drug naltrexone by simply not taking it. The same phenomenon affects medicine more generally where behaviour influences a treatment’s effectiveness. For example, if being prescribed a cholesterol-lowering drug leads a patient to the welcome conclusion that they can eat anything and stop exercising, the drug’s effects may be neutralised and outcomes may even be worse than without it.

Rejecting the ‘brain disease’ formula doesn’t mean that medications or the effort to improve them are unimportant; painkillers calm the ache of a sprained angle, some medications ameliorate the symptoms of a cold, and some old and new intoxicants may relieve the acute pain of a failed love affair, but none of these conditions are normally thought of as brain diseases. However, devoting huge sums to high-tech solutions which could have been used to extend existing treatments seems at the very least questionable.

A disease you can decide not to have

According to the ‘critical neuroscience’ authors cited above (1 2), at a deeper level the dominant conceptualisation of addiction actually shapes the nature of the condition and therefore of its neural correlates, partly by inspiring and legitimating certain responses and de-legitimising or excluding others. These social responses affect the people (self-)diagnosed with the condition, and therefore how the condition itself is presented: “[T]he assumption that the knowledge generated [by neuroscience] has a specific (even normative) authority inspires ambitious reform initiatives – in areas such as mental health, the law, education, child rearing, etc. Thereby, neuroscience actively participates in the creation and stabilizing of the practices, institutions, and classifications that form the condition of existence of specific person types and behavior patterns.”

But even in the USA, this shaping is not strong or pervasive enough to disrupt an underlying pattern in remission from dependence which belies the expectation that drugtaking progressively alters neural functioning in ways which lock the user into addiction. Outside of treatment services, ‘cold turkey’ attempts to end dependent substance use are very common and very commonly succeed. If addiction is a brain disease, given strong enough reasons/incentives, it is one its sufferers can choose not to have.

It is at this point that for its critics the model becomes patently false. A US psychiatrist and psychologist pairing who headlined the disease model a “fallacy” pointed out that “Changing a behavior like addiction requires addicts to work hard to change their patterns of thought and behavior. In contrast, antibiotic cures for pneumonia work even if the patient is in a coma.” Ridiculing Leshner’s brain-disease legacy, British psychologist John Booth Davies titled his polemic, “Addiction is not a brain disease,” arguing that “People cannot decide to give up pneumonia or decide not to be diabetic. They can and do, however, decide to give up their addictions to drinking, smoking and taking drugs, in large numbers … a strong and common sense argument for saying that addiction … does not fit any sensible notion of what a ‘disease’ is.”

At a deeper level, he argues that any explanation of behaviours of this kind which sees them as driven by neural impulses means we must write off the ‘addict’s’ accounts of why they continue to use drugs as illusory, while awarding ourselves and others the dignity of human reason and motivated action – “an act of insouciant egocentrism”, but one entirely in line with Lesher’s contention that “The addicted brain is distinctly different from the non-addicted brain.”

Treatment populations are different

Based on population-wide surveys, studies which find dependence generally remits rather than becoming ever more embedded primarily reflect the usual pattern of remission without treatment. Treatment caseloads lie at the extreme and atypical end of the remission continuum, where relapse is so common that the ‘chronic relapsing brain disease’ model partly fits the facts – not because the brain is stuck, but perhaps because so much else is stuck (1 2 3) in the patients’ lives which generates uncontrolled and continued substance use.

Treatment services are in turn not passive recipients of set-in-stone addictions, but shape the understandings of their patients and therefore how those patients present their addiction. One study has shown that authoritative depictions of addiction as primarily a chronic disease undermine the degree to which drinkers feel they and other substance users can control their use. If this could happen in a short-term study, the researchers expected that “the more frequent and influential exposure [to messages about the nature of addiction] that occurs in treatment settings would have a much more pronounced influence on addiction beliefs. Thus, these results underscore the potent role of health professionals and their enormous responsibility in providing accurate and helpful information about alcohol addiction.”

There it is!

US National Institute on Drug Abuse: Diseased Brain

‘Diseased Brain’ brain scan from the US National Institute on Drug Abuse web site. Caption: “Addiction is a lot like other diseases, such as heart disease. Both disrupt the normal, healthy functioning of the underlying organ, have serious harmful consequences, and are preventable and treatable, but if left untreated, can last a lifetime.”

If addiction treatment is about normalising deviation from societal norms, the brain-disease model renders this deviation physical – it can even be ‘seen’ in neuro-imaging scans of the brain. Par excellence, the brain disease model and its representations in the form of brain scans make an ‘it’ out of addiction – an undeniably ‘real thing’, not merely a failure of motivation and resolve to keep pace with what we know is good for us. Moving in the opposite direction, based on how problem drug use presents itself in practice, the latest US psychiatric classification system (the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders) has abandoned any semblance of an ‘it’, rejecting ‘dependence’ as a category and preferring to define substance use disorders as ranging in an unbroken continuum from mild to severe. These disorders are not diagnosed by brain scans or biochemical tests, but by behaviour, and arguably that is all there is – a set of behaviours we term ‘addiction’ with no underlying pathology, encapsulated by one brain-disease critic as “marked by repeated use despite destructive consequences and by difficulty quitting notwithstanding the user’s resolution to do so”. The behaviours are voluntary, and so in the end is their cessation.

Good intentions

Bolstered by impressive scientific (or pseudo scientific) portrayals of a physical cause, one aim (1 2) of brain-disease model advocates was to challenge conceptions of addiction as a failure of will or morals, destigmatising addicts into the category of victims (of a disease) rather than perpetrators (of a moral failing). There seems no evidence (1 2 3) this has worked, and some that it could backfire. The study referred to above which found that depictions of this model undermine confidence that substance use can be controlled also found no compensatory diminution in the stigma and shame attached to addiction. However, along the way the disease metaphor is consistent with coercion and a policy focus on enforcement to stop potential addicts risking this disease by starting to use.

But the intentions were good, and so too might be some of the effects. As with mentally ill patients, purported sufferers of this disease may seize on the brain-disease model and its representation in brain images as a kind of vindication, proving that something is wrong with them, rather than that they are morally wrong as a person. Absolution from responsibility entails however their diminution in this part of their lives into automata – a dangerous position to accept, which could justify their also being treated by others as not entirely human. Addiction treatment advocates have also seized on the model as a “useful way for particular agencies to convince Congress to raise the budgets [and] it has been very successful”. But for the eminent US addiction psychiatrist Jerome Jaffe, the cash is the fruit of a “Faustian bargain – the price that one pays is that you don’t see all the other factors that interact [in addiction]”.

Last revised 15 December 2017. First uploaded 29 November 2017

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