THE POLITICS OF DRUGS RESEARCH:
A JOURNEY INTO THE COLD
There is a secret controversy in the world of drugs policy – the relationship between science and politics, specifically researchers’ experience of undertaking studies which bring them into conflict with public-sector officials and others in authority. Professor Neil McKeganey warms up our understanding.
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Researchers convey an impression that they apply for research grants, undertake their studies and report their findings. The simplicity of that image conveys an impression of research as a largely trouble-free process of incremental illumination and scientific advance. It is an image that, in relation to drug use and treatment, is as far from reality as it is possible to get.
This article draws on aspects of my own research to illustrate some of the difficulties and challenges which we can face when undertaking research which questions the orthodoxy of establishment opinion.
Speaking truth to power can be discomforting and costly, professionally and personally. But, as Professor David Hunter noted, “We need research and analysis of the type that both challenges and seeks to understand the nature of policy and its impact. [If not] we are seriously failing in our moral duty to speak truth to power”.
ALLYSON POLLOCK’S NHS RESEARCH
One of the few researchers prepared to describe the challenges of research on a politically sensitive topic is Allyson Pollock who, with colleagues, studied the impact of the private finance initiative on the National Health Service (Pollock 2004: 211). That research brought her into direct conflict with both political figures and senior civil servants.
The pressure on her research unit was “destabilising and time consuming; much of our work had to be put on hold while the unit fought for survival. This, no doubt, was the object of the attack” (Pollock 2004: 220).
It appears that when the government felt that one of its main policies was being attacked, it all too easily found itself discrediting the science.
METHADONE – THE QUICK ROAD TO CONTROVERSY
One of the first controversial reports I produced involved looking at drug users’ views of prescribed methadone. For some users, it was a life saver; for others, it compounded their addiction and made their lives infinitely worse. The report based on these interviews – Methadone: Life saver or life sentence? – was presented at an academic conference in Scotland and some newspapers picked up the story. I was quickly asked to attend one of the main drug prescribing agencies in Glasgow on a Saturday morning to explain. Questions came thick and fast from the assembled staff. The gap between what I had written and their views became steadily greater and the session ended with little common understanding.
WHAT DO DRUG USERS WANT FROM TREATMENT?
The next point where I became forcefully aware of the controversy that drugs research can generate arose when my colleagues and I had asked drug users what changes in their drug use they were seeking to achieve as a result of having made contact with a drug treatment agency. Months earlier, when my research team had been designing the questionnaire, the question about drug users’ aspirations from treatment did not strike me as particularly controversial. But the answer to that question turned out to be one of the most controversial areas of my research.
Most of the 1,000+ drug users we interviewed said that they had only one goal, to become drug free (McKeganey et al 2004). Only a tiny proportion said that they were looking for harm reduction support along the lines of advice on how to use their drugs with lower risk.
The drug users’ aspiration to become drug free was at odds with the predominant direction in Scotland which to this day is heavily weighted towards harm reduction. As I began to discuss the research results with colleagues, I constantly found myself having to defend the study and the line of analysis. Academics, drug treatment specialists and civil servants all advised me that it could sow the seeds of discontent, undermining a fledgling consensus in their world of addiction treatment. To me, that sounded an inadequate reason not to explore what drug users themselves wanted to get out of treatment.
I presented an early version of the analysis of drug users’ aspirations to a cross-party group of politicians at the scottish parliament. Halfway through, the chair interrupted to say that he had “heard enough already about abstinence”.
A few months later, I prepared a paper reporting the results of this analysis for a peer-reviewed addiction journal; the editor wrote to say that the paper had been rejected.
I did manage to get the paper published in a different journal (McKeganey et al 2004) where it became clear that it had touched a raw nerve. The Scottish Drugs Forum described the research as “unhelpful and manipulative” (BBC 2004). A presentation to addiction psychiatrists drew strong criticism.
As a result of the press coverage that followed the academic publication, politicians in Scotland and England picked up on the analysis. Questions were asked about whether drug treatment services were sufficiently focused on enabling drug users to become drug free or too focused on maintaining them in a state of continuing dependence. At a medical conference where I presented the research findings, doctors expressed their annoyance that politicians were beginning to express critical comments about the goals of drug treatment.
3% VS 30% DRUG FREE RESULTS
In a followup analysis to the paper on drug users’ aspirations, I looked at how many drug users managed to become drug free almost three years after they started treatment. In the case of those receiving methadone, the proportion was 3%; for those receiving residential rehabilitation, about 30% were drug free.
After the academic paper came out, the scottish media reported the findings. Many articles were stinging in their criticisms of drug treatment services. The Sunday Times ran the headline “Methadone programme fails 97% of heroin addicts”. Annabel Goldie, leader of the Scottish Conservatives, was quoted in The Scotsman newspaper as saying: “Methadone, which is meant to be a bridge, is no such thing as these findings sharply and disturbingly reveal. The way forward, if we are serious about reducing drug addiction and helping to keep more people off drugs, is to expand rehabilitation facilities” (Macmahon 2006).
I was invited to meet the First Minister whose office had issued a statement that “The First Minister respects the work of Neil McKeganey. He is in no doubt that these issues are among the most pressing in Scotland and he is as frustrated as the public about people being in long-term programmes rather than becoming drug free (Barnes 2006:1). He announced that he would expand the residential rehabilitation sector in Scotland and initiate an independent review of Scotland’s maintenance programme.
AN UNWELCOME VOICE
At the end of 2009 with a new drug strategy in Scotland, the minister with responsibility for drugs announced that he was disbanding the main drug advisory committee – a new committee would facilitate the delivery of the new Road to recovery drug strategy and “ask the difficult questions”.
However, when I looked at the membership of the committee, I was surprised that, of 17 available places, five had been allocated to methadone-prescribing doctors and none from the residential rehabilitation sector. There was one retired academic and two places for recovered addicts who could attend on an alternate basis. In The Scotsman, I wrote that this was imbalanced and unlikely to look first at how to reduce the numbers of addicts on methadone, and its meetings should be open to the public.
The minister penned his own article in the following week’s newspaper rejecting what he described as my “cynical, snide and misinformed commentary” and insisting that they would not follow my advice (Ewing 2009).
In between the welcome of 2006 and rejection of 2009, had come a series of underminings of my work by civil servants, including meetings to which people were invited on the basis that they could provide adverse comment on my work.
I had to respond to one civil servant in particular that “there is such a thing as harassment” after a series of official emails from her copied to colleagues.
I realised that senior managers at the University of Glasgow, where I work, had to be alerted. The response from within the university was that the research contract should be terminated on the basis that it was unacceptable for any academic to be working under the level of pressure I was experiencing from the government.
At the same time that these events were unfolding, I was informed that other research I was undertaking was to be audited, requiring me to send civil servants copies of all my interviews with vulnerable participants, all field notes and any other material I had put together – something which, in almost 20 years of research for the government I had never been required to do before. The task was made all the more arduous because I went through everything to ‘anonymise’ all participants in the research papers, to protect them and their children from disclosures made.
We have since been impeded in our research by methadone-prescribing clinicians who have refused access to their patients.
And there have been occasions when my colleagues and I have tendered for research contracts from the government only to be told that we did not even make the shortlist.
INSIDE OR OUTSIDE THE TENT?
For some researchers working in the public-policy arena, there is a view that you stand a greater chance of influencing policy if you secure a position inside the policy tent. For others, the compromises which might be required can seem too great and thus they comment on the decisions of those inside the tent. I believe that having to make such a decision harms the public-policy process and stifles debate on how to tackle some of our most intractable social problems.
The clearest example of this occurred in the publication of Scotland’s drug death figures for 2008: an increase of 26% on the previous year and the highest recorded total to date. Methadone was connected to a third of the deaths. Yet these startling facts failed to generate debate on the failure to reduce drug-related mortality. The only critical voices were opposition parties, with Goldie describing “a wasted decade”.
Why was there such reticence to criticise government policy in the face of such dramatic statistics? Some organisations might fear they would lose their funding. Others felt that their position “inside the tent” could suffer.
To reinvigorate public debate, we need to recognise that dissent is not something to be guarded against, resisted, punished and stifled – but to be encouraged and nurtured. That means rediscovering the value of independent research. It also means rediscovering courage on the part of those undertaking the research, and those disseminating it.
The phrase “evidence-based policy” trips so easily off the tongue as to make one think that there is always a seat available for researchers at the policy-making table, and that authority will be receptive of the research. The reality can be very different.
NEIL McKEGANEY is professor of drug misuse research at the Centre for Drug Misuse Research, University of Glasgow. His latest book is Controversies in Drugs Policy and Practice (ISBN 978-0230235953).