Our refusal to acknowledge that drugs can be a happy experience is hampering our attempts at treatment, says Nick Goldstein. Read the full article in September DDN magazine We’ve all heard enough about coronavirus to last a lifetime. But one of the more positive aspects of the lockdown is that it has given us time and space to sit down and think about the difficult issues that we kick into the long grass. One of the subjects I find repeatedly cropping up is pleasure – our perception of pleasure and our attitude towards it. The dictionary definition of the noun ‘pleasure’ is a feeling of happiness and enjoyment – a feeling we all know. Pleasure is usually perceived to be harmless – a fringe benefit of existence even – BUT if that pleasure is derived from something society perceives as a negative, all hell breaks loose. And there are few things society regards as negatively as drug use. Consequently, drug use has become deeply stigmatised and the root of that is ‘intoxophobia’ and faulty misperceptions of pleasure. Intoxophobia, the fear of intoxication, has been around for a long time and exists as a result of ignorance of different, altered states of consciousness. Any behaviour different to our norms creates fear, and no one likes to be scared – in fact fear makes people angry. The misperception of drug use as purely pleasurable is also the result of ignorance – an ignorance that also ends in anger, but this anger is caused by resentment rather than fear. Think of it as a version of Max Weber’s protestant work ethic – a concept that implies that pleasure must be worked for, striven for, and not bought by the ten bag. So, some poor schmuck wandering around high as a kite doesn’t go down well because of all those misconceptions, misperceptions and outright intolerance relating to pleasure. Sadly, those misconceptions and misperceptions surrounding drug use and pleasure exist in the substance misuse field too. From key workers to consultants in every treatment agency and treatment provider, it’s lurking. It can be seen in the drugs prescribed (both major drugs prescribed in treatment, methadone and buprenorphine, are perceived to offer little pleasure) and in the limited amounts prescribed, which are subsequently sub-optimal. Have you ever heard a prescriber say to a struggling client, ‘Oh dear! Your sample is positive. You’re obviously struggling with this dosage/prescribed drug. So let’s increase your dose/change the drug for something you might prefer – something you might actually want to take because you enjoy it.’ No, me neither. The response is much more likely to involve decreasing dosage and increasing restrictions for the client. Rather than concentrate on Freud’s pleasure principle, it would be far better for us all if more emphasis was paid to a much earlier commentator, Epicurus. Epicurus, who was a noted Greek philosopher, suggested that primarily pleasure was found in relieving pain. At least 50 per cent of substance misuse clients experience dual diagnosis and suffering. The very fact they use drugs and fall into the sphere of substance misuse services is a grim indictment of modern psychiatry, because no one goes into substance misuse treatment if they have another option. Gabor Maté’s ideas around trauma and addiction would suggest an even higher percentage of service users are suffering. Put simply, people don’t go into treatment to keep the party going, for free dope. Considering the modern treatment service, it can easily be construed that you have to be desperate to sign up. So it would be great if the drugs that enable clients to function and provide much needed stability were not seen as a vice or pleasure, but rather seen as just medication. I’ll probably be burned at the stake for mentioning it, but demonisation of drugs and the pleasure they can impart is seen far too often in recovery settings. I appreciate the seriousness of recovery, but if your schtick involves demonising drugs and pleasure to maintain one’s own recovery it might be time to find another narrative. Our negative attitude to pleasure can even be seen to limit the effectiveness of what little harm reduction we practise. The work of Magdalena Harris, associate professor at the London School of Hygiene and Tropical medicine and a leading researcher, suggests that the most effective forms of harm reduction tend to fall around ways to extend pleasurable drug use rather than the much more common and more ineffective ‘wages of sin are death/do this or die’ approach. A more civilised attitude to pleasure would change things, and our only chance of this is a full and frank discussion around pleasure and our attitude to it. An inability to accept pleasure is the elephant in the room. It leads to stigma, poor drug treatment and poor relationships between services and service users. This, sadly, won’t change until there’s been a debate – and considering the subject, it will be a painful debate. Nick Goldstein is a service user My contribution to this debate is this. Since mankind came down from the trees we’ve wandered around, and when hungry we ate some of the plentiful plants. Some plants nourished us, so we kept eating them. Some plants poisoned us, so we stopped eating those. And some plants – special plants – made us feel good… really good. We definitely kept eating them! You have to accept pleasure is a very human problem, because only mankind would make pleasure a problem. Most animals, wisely, just enjoy it.