Alcohol dependence in public policy: towards its (re)inclusion

Individual behavioural change: contemporary policy

Public policy aimed at reducing alcohol misuse in Scotland and England currently gives priority to changing the harmful drinking behaviour of individuals. ⁶ In this respect, binge drinking has received considerable attention due to its association with public drunkenness, antisocial behaviour and acute harms. ^3,4 Public health information campaigns such as ‘Know your Limits’ (England) and ‘Don't Push It’ (Scotland) endeavour to raise awareness of the dangers of drinking to excess in a single session. ⁷ The primary strategy employed by policy to control such misuse is the promotion of informed choice or ‘sensible drinking’ through education initiatives, which it is hoped will alter individual behaviour. ^3,4

The focus on individual choice and personal responsibility allows the government to address the costs and harms associated with alcohol misuse without imposing unpopular restrictions on individual liberty. However, as Faden has highlighted, public information strategies of this kind have been criticized for amounting to nothing more than ‘token efforts’ to deal with politically sensitive issues. ⁸ Indeed, alcohol policies in the UK that employ information provision as a central component have been widely criticized as a ‘recipe for ineffectiveness’. ⁹

Changing drinking environments: conventional public health

Alcohol harm control policies can also use strategies to manage consumption at a population level. ¹⁰ Concerns over the failure of education-based alcohol policy in the UK have led to calls for such alternatives to be introduced. ^5,11 This turn to more conventional public health measures, like price increases and restricted hours of sale, is supported by a greater commitment to the public (common) good and an awareness of the role the environment plays in sustaining or jeopardizing health. A recent example of this approach is the report by the BMA entitled Alcohol Misuse: Tackling the UK Epidemic. ⁵

The BMA report surveys rates of alcohol consumption in the UK, identifies the burden alcohol misuse imposes on society and charts effective approaches for managing these costs and harms. The report notes that the UK is one of the largest consumers of alcohol in Europe, ¹² and that around 90% of the population drink alcohol ¹³ ; of this group, the majority drink in moderation. But the BMA highlights that alcohol misuse contributes to significant health harms and increased levels of crime and social disorder. In addition, alcohol misuse undermines road safety, contributes to lost productivity and spurs familial breakdown. ¹⁴ It has been estimated that the annual social cost of alcohol misuse in England is around £55.1 billion and in Scotland £1.13 billion. ¹⁵

Despite the costs and harms that alcohol misuse generates, the BMA stresses that there ‘… is a substantial body of evidence demonstrating that targeted and population-wide alcohol control policies can reduce alcohol-related harm’. ¹⁶ The BMA recommends that the current reliance of UK policy on education campaigns should be replaced or supplemented by these proven strategies. More precisely, it calls for the introduction of alcohol policies that control the availability and price of alcoholic beverages, cultivate responsible retail practices, address drink-driving, maintain educational initiatives as part of a wider alcohol strategy, use early intervention and treatment programmes. In addition, the BMA argues that national policies should be based on international cooperation. ¹⁷

Alcohol dependence in Alcohol Misuse: Tackling the UK Epidemic

The BMA notes that alcohol has addictive properties and binge drinking ‘… significantly increases the risk of alcohol dependence…’. ¹⁸ In its survey of alcohol misuse, the BMA reports that between 1.1 and 2.9 million people in the UK are dependent on alcohol. ¹⁹ Dependence is identified as being linked to various health harms including psychiatric impairment, cardiovascular disease and liver disease. ²⁰ The condition is also associated with a wide range of social harms. In this respect, the report quotes a member of the BMA as lamenting that dependence ‘… destroys individuals and slowly but inevitably pulls the family down on the back of “they like their drink”’. ²¹ The BMA emphasizes that individuals who have dependency problems can benefit from specialist treatment programmes – if they consent to participate. ²² For this reason, it calls for the funding of treatment services to be ‘significantly increased’. ²³

Targeting policy: a partial portrayal of dependence

The BMA uses the definition of alcohol dependence employed by the World Health Organization in International Classification of Diseases (ICD-10). ²⁴ This account requires the identification of various signs and symptoms for a positive diagnosis of dependence syndrome (Box 1). ²⁵

With respect to the first criterion, the BMA refers only to ‘a strong desire’ to take the substance. ²⁶ It does not mention the more extreme compulsion that the dependent can experience and which is included in ICD-10. However, the BMA does refer to the experience of one of its members who treated a patient so desperate for alcohol that they resorted to drinking nail varnish and hair spray when their alcohol supply dried up. ²⁷ This type of desperate action is all too familiar for those who treat or live with alcohol dependence. It also casts doubt on the decision to present dependence as involving only a ‘strong desire’ and explains why the WHO insists that a ‘… central descriptive characteristic of the dependence syndrome is the desire (often strong, sometimes overpowering) to take psychoactive drugs…’. ²⁸

When explaining why individuals misuse alcohol the BMA suggests that, in the case of dependent drinkers, this relates to the ‘need to overcome symptoms of withdrawal’ and tolerance (the need to consume more of a substance to achieve the original effect). ²⁹ The BMA omits from its explanation of why people with dependency problems misuse alcohol any reference to impaired control, compulsion or craving. ³⁰ The BMA's selective use of its chosen diagnostic tool raises concern over how fairly and accurately dependence is represented within its recommendations. This is an important issue because without a clear account of the nature of dependence, neither dependent drinkers nor their close contacts, nor wider society, nor general practitioners can begin to understand how they should respond to the condition.

Incorporating dependence in population-focused policy

The implicit suggestion within the BMA report that preventing lower levels of alcohol misuse in the population will have a positive impact on levels of dependence is important. ³¹ This is not least because the BMA recommends measures that have been shown to effectively control alcohol misuse within populations. However, relying on general public health policies to address dependence is insufficient because, in their present form, the recommendations do not take account of the public challenges that confront the dependent and their close contacts. This point can be explained by drawing on the social obstacles that confront treatment initiatives.

The BMA identifies the need to improve treatment for alcohol misuse. But it notes that even when treatment is offered to people with dependency problems ‘… many may not be willing to accept treatment places…’. ³² The BMA does not explore the reasons for this. However, part of the explanation for why people refuse treatment, or even refuse to admit that they have a problem with alcohol, relates to the negative attitudes and stigma that surround dependency. ^33,34 People living with dependency problems must strive for recovery (often relapsing along the way) within communities and families which often despise them and/or their condition. If dependent drinkers are to be diagnosed and feel able to enter and remain in treatment programmes then the stigma which surrounds the condition must also be addressed. This requires (re)incorporating alcohol dependence within public policy and educating the public about the condition. It is important to emphasize that the characteristics of dependence should be understood within the public forum and not only by specialist professional groups.

However, the recommendations that the BMA makes about education and alcohol misuse focus primarily on the need to make sensible drinking guidelines clearer to consumers. The report does recommend that the public should be made aware of the ‘… adverse effects of alcohol misuse…’ but makes no reference to dependence. ³⁵ Thus, it is unclear whether the intention is to cultivate an understanding the inter-relationship of different forms of alcohol misuse. Unless clarity is provided on this point, it is likely that the addictive qualities of alcohol and the nature of dependence will remain, at best, clouded within public discourse.

Choice-focused policy and impaired agency

The current focus on individual choice is problematic for a number of reasons. First, it fails to attend to the social influences that can positively and negatively influence dependency. Second, the promotion of individual choice overlooks the fact that those with alcohol dependence syndrome have, by definition, an impaired capacity to make healthy choices about their drinking. Choice-based policy implies that all excessive drinkers are able to choose to stop drinking. This suggestion is too simplistic and likely to further problematize the way dependent drinkers are perceived within society. Despite the impaired agency that characterizes dependence, there is a growing consensus that those who are dependent have responsibilities for their own drinking. ³⁷ This makes it important for policy to articulate what these responsibilities might be and identify how individuals can be supported to attain them.

Alcohol dependence as a public issue

Alcohol dependence impacts on all members of society whether via direct experience of the condition or the costs and harms it imposes. In addition, the environments that exacerbate an individual's drinking will often serve as cues to relapse after periods of abstinence. ³⁸ The role social factors play in influencing an individual's drinking has led Levy ³⁹ to suggest that society has a responsibility for the drinking of a dependent person. The social responsibilities that exist with respect to dependence must be articulated within policy if they are to become public currency. Without this approach, it is likely that the dependent will continue to be dismissed as the local drunk, or as a self-harmer who warrants little public assistance, except treatment when they have ‘hit rock bottom’. However, if presentations of dependence as a chronic, relapsing brain disease are correct then it is wholly inadequate and morally reprehensible for policy not to articulate how it intends to address dependency as a public and not just a treatment issue. ⁴⁰

Addressing stigma and shame

Another reason why it is important to generate a public response to alcohol dependence is that, unlike other forms of alcohol misuse, it is thoroughly stigmatized within society. Stigma is well known to undermine public health. ⁴¹ In the context of dependence (addiction) Erickson highlights the fact that ‘negative stereotypes… stigma, prejudice, anger, and misunderstanding’ that surround addiction have ‘killed many people’. ⁴² This starkly highlights the need for policy to identify and overturn these prejudices by cultivating a greater awareness and understanding of dependence (addiction) as one type (or degree) of alcohol misuse. Nussbaum makes the point that Alcoholics Anonymous, which is widely seen as among the most successful programmes available to support recovery from alcohol dependence, has at its heart a commitment to avoid shaming its members. ⁴³ Ultimately, public policy should aspire to create societies that are similarly supportive. The failure to incorporate dependence within public policy misses this opportunity to help cultivate such environments. As a result, social marginalization will continue to harm the recovery chances of the dependent and frustrate clinical endeavours to treat the condition.