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The politics of addiction: Medical conflict and drug dependence in England since 1960, by Sarah G. Mars

In recent years, there has been considerable public and political discussion on the issue of drug treatment. The launch of the Coalition Drug Strategy in 2010 reignited debates on the relative merits of treatments centred on maintenance, recovery and abstinence, and recent media interest – sparked by celebrities such as Russell Brand – has emphasised criticisms of methadone maintenance in particular. Public discourse on this issue is often carried out in broad strokes (abstinence v maintenance, harm reduction vs. crime prevention and so forth), which imply that drug treatment debates are a matter of choosing between two well-defined sides. In her book The Politics of Addiction, Sarah G. Mars provides much-needed background to these arguments. By placing recent controversies in a longer historical context, she is able to demonstrate that behind the big questions over treatment approaches are an array of institutions, individuals and social processes, which have influenced practice at least as significantly as any scientific developments. Covering the period from 1960s to the present day, Mars’ meticulously researched book sets out the history of drug treatment debates over the period, and in doing so reveals a complex and fractious interplay of competing forces within the world of medical provision, policymaking and academic research. The book addresses a number of key themes. On one level, it is a history of how approaches to treatment shifted from the famous ‘British System’ of GP-centred prescribing, through the Drug Dependency Units (DDU’s) established in the late 1960s, to the more inclusive harmreduction approach of the mid-1980s and the return to a more punitive, but also abstinence-centred, paradigm from the 1990s onwards. However, it is also about how power operates across and between influential institutions. It is, to a large extent, about the conflict between ‘public’ provision (centred in the DDU’s) and the work of independent prescribers operating on the margins of their own profession. It is about the mechanics of health policymaking, and the powerful coalitions – and individuals – who can dominate that process. It is also about the complex relationship between scientific evidence, individual commitment and political practicality in the world not only of drug treatment but medical policy more broadly. At the heart of the book is the conflict between the Drug Dependency Units, which dominated treatment from the late 1960s onwards, and the private prescribers who continued to treat patients, often using methods at variance with those employed by DDUs. It is a story of divergent treatment philosophies, but also of clashing medical cultures: the NHS establishment against the private maverick; the specialist against the generalist; and, to some extent, the bureaucrat against the social entrepreneur. What Mars reveals is an evolution of treatment driven only in part by changes in the evidence-base. In her analysis, treatment development is driven equally by the shifting allegiances of civil servants, the establishment of powerful practitioner and informal knowledge networks, disciplinary protectionism, departmental wrangling and the vagaries of social change. Certainly, she demonstrates the extent to which AIDS shifted public and political thinking on drug treatment towards harm reduction in the 1980s, but this is a rare example of a singular, and catastrophic, external influence changing practice. At other times, practice is shaped by funding opportunities, political calculation, experiential knowledge (as much, and perhaps more than, peer-reviewed evidence) and the perspectives of powerful figures in Whitehall. The book is the result of extensive archival and interview-based research, and at times the narrative arc is somewhat lost in the mass of detail. Readers not familiar with the basic chronology of drug policy over period may find themselves struggling to keep a track of the bigger picture at times. There are also moments where the author’s sympathies stand out rather visibly: Dr Ann Dally, in particular, is treated with marked admiration that slips, occasionally, from the professional into the personal. Mars’ sympathetic discussion of Dally’s treatment at the hands of the GMC is understandable, but the repeated references to her great social skills (and her schooldays with Margaret Thatcher) add less to the analysis. There is, buried in the descriptive material, a potentially powerful critique of Foucauldian perspectives on power which ignore the everyday – and, sometimes, rather dull – realities of professional