Volteface launched ‘Black Sheep: An Investigation into Existing Support for Problematic Cannabis Use’ on the 7th of February.
Dr Will Haydock spoke on the panel at the launch event – here are his reflections:
My background as an academic is really in alcohol policy, where I’ve always been frustrated by the adversarial relationship between ‘the industry’ and ‘public health’. Anyone who’s followed the debates around minimum unit pricing (MUP), for example, would struggle to identify a monolithic ‘industry’ position, given that plenty of brewers and retailers like the idea of MUP, but plenty of other organisations don’t.
The launch of the Black Sheep report, and some of the social media discussion around it, was eye-opening for me, to find that this same adversarial approach seems to characterise drug policy – even drug treatment – debates. As a commissioner of substance misuse services, the idea that cannabis can cause some people problems is uncontroversial. And as the Black Sheep report points out, the number of people coming into treatment citing cannabis as an issue has increased considerably in the past 10 years. It’s hard to ignore that when you’re thinking about the funding of these services.
But apparently, as Paul Hayes joked, cannabis is the only substance known to humanity that is completely harmless.
Of course, the reality is much more complicated than whether cannabis is harmful or not. The effects of a substance are determined not only by its inherent chemical properties, but also the social context in which it’s taken (including the mode of administration), and the characteristics of the individuals involved, who might have certain physiological or psychological predispositions.
Research, evidence and policy responses are much easier when things can be understood in a simpler way. When we can agree that sharing injecting equipment increases the risk of blood borne viruses like HIV or Hepatitis C spreading, needle exchange seems a reasonable solution. When we can identify something called physiological dependence on opiates or alcohol, we can prescribe medication to assist with withdrawal.
But ‘addiction’ or a ‘substance use disorder’ (or ‘problematic cannabis use’, as it’s described in Black Sheep) is more complicated than physiological dependence; it brings in all that messy ‘social context’ or, more simply, life.
As Chris Ford pointed out at the launch of Black Sheep, most people who try any substance don’t go on to have any particular issues with it, and most people who do have issues are able to overcome them on their own –or at least without accessing formal NHS-style treatment services. The people who have the most difficulty in overcoming an issue are often those who lack some of the resources other people have. I don’t just mean the financial resources to pay for a stay in the Priory. (And I should point out that every local authority gets a budget to fund local services for substance misuse free at the point of use.) I mean that your chances of success in treatment are affected by whether you’ve got a stable relationship, job, home, and so on.
So when we talk about addressing ‘problematic cannabis use’, are we really talking about cannabis? The whole nature of the issue means that it doesn’t really make sense to talk about ‘drug treatment’ – which, to be fair, the report doesn’t; its sub-title refers to ‘existing support’. But it’s still referring to ‘existing support for problematic cannabis use’, when the cannabis use can be only a part of the picture. It’s harsh to hold treatment services to account for outcomes relating to housing and employment, for example, when these are largely out of their control and there are in fact other organisations like local authorities or Job Centre Plus that should be delivering on them.
Interestingly, this is where you can start to get agreement across that great divide in drug policy debates. If we can agree that problems with substances should actually be viewed as problems people have (as we did on the panel last Tuesday), then we can bypass the discussion of how harmful cannabis is as a substance.
And there are advantages to this approach. If we’re serious about trying to reduce drug-related harm, we should be thinking not (just) about cannabis use, but a broader set of social and political problems relating to housing, employment, education, and so on. We’d start discussions with reference to specific harm, rather than a substance.
And this is a crucial point for the provision of support services or interventions, which have been too often siloed, so that there’s one service to address a person’s weight, another one for alcohol consumption, and yet another one for smoking. And of course another if you’re using any illicit substance – like cannabis.
But broadening the issue out to what Nick Heather has called ‘problems of living’ in relation to addiction has its own problems. You can’t write a sensible or coherent report about something as broad as problems of living, and you might well be drawn into the facile truisms of recent debates about public sector reform where we’re told that we need to integrate health and social care better (that one was on Question Time last Thursday), or that the bodies that commission public services are too fragmented and need to be joined up, or that we need to look at the ‘whole person’ when designing services.
These calls for integration dodge the question. There will always need to be some way of dividing up responsibilities and budgets; there will never be one ‘social issues’ budget. One attempt to cut this Gordian knot has been the call for personal budgets, which would lead to one budget for each ‘whole person’. But that falls down when we find that no man is an island, and some form of coordination is helpful when you’re dealing with things that might be public goods or natural monopolies.
So, given this impossibility of really identifying or addressing ‘the (single) problem’ easily, I can understand why this specific report focuses on cannabis. It’s ridiculous to expect any single report to properly address ‘the drug problem’.
There’s no question a report would need to take a particular focus. The issue is whether this is the right focus.
In the panel debate, Paul Hayes and I both expressed some concern as to whether expanding or improving treatment for cannabis users was a practical demand at a time when Public Health budgets will have been cut by 20% by the year 2020, at which point they will be reduced to zero, with any funding coming from local authority business rates. In a world of scarce resources, aren’t the costs and risks relating to use of alcohol, heroin and crack cocaine going to be more of a priority for budget holders?
But my point here is in a sense more about campaigning strategy. The reason drug treatment got more funding under New Labour was as part of its attempt to be ‘tough on the causes of crime’. As Paul Hayes put it himself, when talking to service users, ‘because you are seen as a threat, the government is prepared to spend money on drug treatment’.
And the argument put forward in Black Sheep is that the current situation as regards cannabis is so worrying that a legal, regulated market is an appropriate response: prohibition is causing unnecessary harm and costs on society.
So, despite Paul Hayes’ discomfort with the VolteFace conclusions, on first sight the tactics look remarkably similar. Both are appeals to fear, rather than our better natures.
Maybe we’re in a situation now where heroin use isn’t so relevant or frightening to the general public – it’s not a threat; it’s tragic. And there’s no doubt that acquisitive crime – at least in the sense of theft or robbery in person – isn’t the concern it was 25 years ago. That would undercut the NTA / New Labour approach of being tough on the causes of crime.
Crucially, there is a key difference between the NTA and VolteFace approaches. The NTA argument was founded on a fear of the other. We should fund treatment for opiate and crack users because they commit crime and transmit deadly viruses. We’re afraid that we (or those we love) will be harmed by heroin users. The argument of Black Sheep, though, is more about caring for the individual user: we’re afraid that we (or those we love) will be problematic cannabis users, and suffer harm that can’t be remedied by existing public services.
This is a fundamentally different way of framing drug policy debates.
I don’t know whether the conclusions of Black Sheep are either wise or even achievable, but I look forward to seeing how this approach plays out in policymaking circles. And maybe playing on people’s fear for themselves or their loved ones is less stigmatising than basing policy on their fear of other people.
Dr Will Haydock is a Visiting Fellow in the Faculty of Health and Social Sciences at Bournemouth University, Senior Health Programme Advisor for Public Health Dorset, and writes regularly on drug and alcohol use on his blog Thinking to some purpose. Tweets @WilliamHaydock