Image: Nocturnal Beer Cave from byronv2's Flicker PhotoStream
Nor thieves, nor covetous, nor drunkards, nor revilers, nor extortioners, shall inherit the kingdom of God’ Corinthians 6:10

Alcoholism is situated in a very particular place in relation to public opinion, health and social services and research. Though it is incorporated into a medical pathway of diagnosis and treatment, it is a socially experienced condition. More so, perhaps, than other health conditions, in that all aspects of alcoholism are social. The purchasing of alcohol, the consequences of drunken behaviour, the presumed and evidenced causes of alcoholism in the first instance, all centre around social and interpersonal interactions. Problem drinking, alongside other substance abuse and mental health conditions, is stigmatised. It is inextricably tied up with morality and character judgements dating back to, and beyond, the biblical example above. Blame, responsibility and deservingness are features of how alcoholism is understood and reflect wider social policy considerations regarding who deserves state support and healthcare, and who does not. In this post, we explore how and if these issues have shaped the resources alcoholics in Scotland can access, and their implications regarding healthcare, service provision and support for problem drinking and substance abuse.

Scotland is associated with higher levels of drinking than the rest of the UK, both in public health and policy terms, as well as popular culture. In recognition of this, the devolved government introduced a Minimum Unit Pricing (MUP) policy in May 2018. The policy had the long-term aim of reducing the number of hospital admissions resulting from alcohol-related health issues over a 20 year period. MUP targets the nation’s problem and harmful drinkers by making unaffordable previously low cost, but high alcohol content drinks, typically purchased by low-income drinkers. It is a universal policy, and therefore, ostensibly, one that does not draw on subjective judgements relating to deservingness. It should have the most impact on the poorest, without singling them out. MUP is not designed to reduce overall alcohol consumption, but to have an effect on those being most damaged by alcohol, and to halt the trend over the last 30 years of increased mortality and harm within that population group.

Though there is some, limited, evidence that MUP has a positive impact: Canadian MUP has resulted in a reduction of alcohol-related criminality and in Scotland, the sales of some cheap high alcohol content ciders has reduced, there are still problematic social and health implications for alcoholics that can be linked to the stereotypes and assumptions relating to their condition. A key feature of the resources available to problem drinkers is that despite some absorption into the medical model, the treatment of alcoholism is largely social. Alcoholics Anonymous (AA), signposted on the NHS Scotland website and in GP consultations, offers a spiritual answer to addiction.  Funded by attendees, it has strong religious overtones – no sect or denomination but an emphasis on seeking a Higher Power – the programme they offer is spiritual and finds its basis in Christianity and a belief in God. This focus is significant for a number of reasons. Firstly, it avoids the medical model of alcoholism to maintain blame; to call alcoholism a disease, and respond to it as such, removes the element of decision-making, responsibility and blame associated with drinking. Secondly, it maintains an individualised model of provision, if you are not one of the 5-8% of drinkers who remain sober after a year of accessing support, it is your fault that you have failed, because you have not tried hard enough. Incidentally, other medical services across Scotland, and the world, also use the 12 step program advocated by AA, meaning that this social, individualised focus is maintained in medical services.

Even at this individualised level, problem drinkers are likely to require detoxification services and specialist support, both of which, unsurprisingly, are difficult to access. There are a range of service providers and charities in Scotland that profess to offer addiction-focused services. There is little consistency across the nation unfortunately. In Dundee for example, though there are a selection of organisations that list addiction services as a specialism when you search for their available services in Dundee, they might only have services for learning disabled adults or mental health service users. Specialist services then are actually delivered by universal support providers with limited expertise, and there is a postcode lottery for services that does not necessarily map onto the areas of greatest need. Returning to the notion of deservingness, these services default again to models of conditionality.  The ‘Pause’ initiative in Scotland required women to take birth control to access addiction recovery services. Ethically dubious at best, eugenics at worst.

Another fundamental to being deemed deserving, other than not being responsible for your misfortune, and to meet certain conditions, is to be in need. An ongoing feature of alcohol and drug misuse services is their sustained focus on the users of those using narcotics, not alcohol. A complication in the provision of these (often profit-making) organisations is that they respond to capricious alterations to policy and government agenda, as well as a race to the bottom in terms of cost. Many of the services are targeted, and respond to what has been referred to as a ‘drug crisis’ in Scotland including harm reduction services and needle exchange. In reality, they are services for those addicted to substances other than alcohol. A cynic might suggest that this is to appear to offer the broadest possible service, to secure local authority tenders, but then only offer specific or limited services to those deemed more in need. Much of the support available to those with alcohol addiction could be considered free labour, invited often to volunteer or become involved in peer-to-peer support – continuing with the implicit conditionality associated with independent services such as AA.

So low-income alcoholics cannot afford alcohol and do not have access to adequate resources. Limiting access to alcohol does not alleviate addiction, it only restricts access to the substance of use. A previous post on this blog reflects on how MUP does little to address the causes of alcoholism, referred to in the blog as a ‘drug of solace’. Concerns have been raised that vulnerable people would switch from alcohol to cheaper substances as a result of MUP, though these concerns have not been substantiated, and in some instances are being proliferated by those invested in the continued sales of alcohol. It might also be relevant to question whether problem drinkers might only be able to access state-funded support on the condition they are addicted to a ‘hard’ substance rather than alcohol. Potentially further driving demand for drug addiction specialist services over alcohol addiction services, and continuing the problematic omission of adequate alcohol addiction support services in Scotland. It might also then provide the Scottish government with further ammunition to challenge the UK Drug Misuse Act (1971), and develop a programme for decriminalisation, turning alcoholics, essentially into collateral damage at the altar of independence. With Boris Johnson’s recent rejection of a second Scottish Independence referendum, a remaining option to the SNP is to lobby for as many devolved policies as possible, though this is highly speculative.

Despite ‘universal’ public health strategies to address problem drinking in Scotland, neither policy nor support service provision addresses or challenges the hangover of centuries of blame and shame associated with alcoholism. People experiencing alcohol addiction are abandoned and left to fall between the cracks of services in the disjointed interaction between public health initiatives, political priorities and continued withdrawal of the state. Allowing a division between undeserving and deserving with regard to accessing state support and healthcare has painful implications for the future. It creates a boundary with gatekeepers who can withhold vital services, pushing people into desperate situations to evidence need or creating a willingness to agree to increasingly extreme and unfair conditional measures. Alcoholics abandoned now, who will be abandoned next

About the Author: Ramsay Meldrum is a singer/songwriter who has lived experience of alcohol addiction and poly-substance abuse, and has actively engaged with, and survived and/or benefited from involvement with various recovery services*. He is a fan of café coffees and conversation and overuses the phrase ‘Hakuna Matata’.

*Since becoming sober, his looks have improved, but his attractiveness to potential Tinder dates has dramatically declined.