Addiction screening and diagnostic tools: ‘Refuting’ and ‘unmasking’ claims to legitimacy

Enacting alcohol realities: gendering practices in Australian studies on 'alcohol-related presentations' to emergency departments

'Alcohol-fuelled violence' and its prevention has been the subject of recent intense policy debate in Australia, with the content of this debate informed by a surprisingly narrow range of research resources. In particular, given the well-established relationship between masculinities and violence, the meagre attention paid to the role of gender in alcohol research and policy recommendations stands out as a critical issue. In this article, which draws on recent work in feminist science studies and science and technology studies, we focus on the treatment of gender, alcohol and violence in Australian research on 'alcohol-related presentations' to emergency departments (EDs), analysing this type of research because of its prominence in policy debates. We focus on four types of 'gendering practice' through which research genders 'alcohol-related presentations' to EDs: omitting gender from consideration, ignoring clearly gendered data when making gender-neutral policy recommendations, methodologically designing out gender and addressing gender in terms of risk and vulnerability. We argue that ED research practices and their policy recommendations reproduce normative understandings of alcohol's effects and of the operations of gender in social arrangements, thereby contributing to the 'evidence base' supporting unfair policy responses.

When the Brain Leaves the Scanner and Enters the Clinic

Addiction neuroscience promises to uncover the neural basis of addiction by mapping changes in the “diseased brains” of people with “drug addictions.” It hopes to offer revolutionary treatments for addiction and reduce the stigma experienced by those seeking treatment for a medical, rather than moral, condition. While the promises of addiction neuroscience have received considerable attention, relatively few studies have examined how neuroscientific discourses and promises play out in drug treatment settings. Instead of asking how neuroscience might measure or treat a preexisting addiction “problem,” we draw on poststructuralist ideas to trace how neuroscientific discourses produce addiction as a certain type of “problem” and the effects of these particular problematizations. Based on interviews with a range of different types of treatment providers working in Victoria, Australia, we discuss three themes that reveal neuroscientific discourses at work: (1) constituting pathological subjects, (2) neuroplasticity and “recovery,” and (3) the alleviation of guilt and shame via references to the “diseased brain.” On the basis of our analysis, we argue that dominant neuroscientific discourses produce patients as pathologized subjects, requiring medical treatment. We also contend that the intersection of neuroscientific and recovery discourses enacts “recovery” in terms of brain “recovery” through references to neuroplasticity. Further, when neuroscientific and moral discourses intersect, addicted subjects are absolved from the guilt associated with immoral behavior emerging from a “hijacked brain.” We conclude by emphasizing the need for future critical work to explore the complex ways in which neuroscientific discourses operate in localized care ecologies.

Does outcome measurement of treatment for substance use disorder reflect the personal concerns of patients? A scoping review of measures recommended in Europe

There are a growing number of authors stating that outcome measurement in treatment for substance use disorders should go beyond substance use and include other bio-psycho-social variables of interest. However, little is known about which topics tend to be covered by outcome measures and whether they reflect the typical concerns of this patient group. This study followed a scoping review methodology in which 42 outcome measures recommended by an EU agency for substance use disorders were reviewed. We identified the domains of problems covered by these 42 measures and then compared them with 54 domains derived from patients, in a previous study. We also explored how similar the existing measures were in terms of domains covered, and which patient derived domains tended to be represented in those measures. We identified 31domains of problems across the 42 measures, with 'substance use' and 'psychological health' among the commonest. Most measures were similar in content to each other and multidimensional. Almost all domains of problems identified in the outcome measures corresponded to concerns reported by patients. On the other hand, we found that several topics of relevance for patients were not covered by any of the measure included in our study. This suggests that existing outcome measurement does not always target aspects that affect patients' lives, as reported directly by patients. Our study shows that outcome measurement needs to adopt a more flexible and comprehensive approach, by taking on board the problems experienced by patients in this population.

"What constitutes a 'problem'?" Producing 'alcohol problems' through online counselling encounters

Typically, health policy, practice and research views alcohol and other drug (AOD) 'problems' as objective things waiting to be detected, diagnosed and treated. However, this approach to policy development and treatment downplays the role of clinical practices, tools, discourses, and systems in shaping how AOD use is constituted as a 'problem'. For instance, people might present to AOD treatment with multiple psycho-social concerns, but usually only a singular AOD-associated 'problem' is considered serviceable. As the assumed nature of 'the serviceable problem' influences what treatment responses people receive, and how they may come to be enacted as 'addicted' or 'normal' subjects, it is important to subject clinical practices of problem formulation to critical analysis. Given that the reach of AOD treatment has expanded via the online medium, in this article we examine how 'problems' are produced in online alcohol counselling encounters involving people aged 55 and over. Drawing on poststructural approaches to problematisation, we not only trace how and what 'problems' are produced, but also what effects these give rise to. We discuss three approaches to problem formulation: (1) Addiction discourses at work; (2) Moving between concerns and alcohol 'problems'; (3) Making 'problems' complex and multiple. On the basis of this analysis, we argue that online AOD counselling does not just respond to pre-existing 'AOD problems'. Rather, through the social and clinical practices of formulation at work in clinical encounters, online counselling also produces them. Thus, given a different set of circumstances, practices and relations, 'problems' might be defined or emerge differently-perhaps not as 'problems' at all or perhaps as different kinds of concerns. We conclude by highlighting the need for a critical reflexivity in AOD treatment and policy in order to open up possibilities for different ways of engaging with, and responding to, people's needs in their complexity.

Producing “Progress” Through the Implementation of Outcome Monitoring in Alcohol and Other Drug Treatment

Outcome monitoring—a process in which clinicians use standardized tools to routinely measure client “progress” on predefined outcomes of interest over time—is increasingly being implemented in alcohol and other drug (AOD) treatment services as a way of demonstrating quality of care. However, relatively little is known about the implications and unintended consequences of implementing outcome monitoring in clinical and social practices. In this paper we draw on qualitative data emerging from focus groups with clinicians who piloted an outcome monitoring tool in Melbourne, Australia, using conceptual tools drawn from science and technology studies. Rather than acting as a stable empirical object, we argue that realities of progress are enacted multiply in relation to preexisting treatment discourses and policy, organizational practices of data collection and management, reporting tools, and clinician attitudes and practices. In particular, we trace how the tool orders the “problem” of drugs differently to the qualitative mode of ordering; how different modes of ordering progress hang together and the tensions and coordination strategies that are involved. And finally, we highlight an unintended consequence of the outcome monitoring process—the enactment of vulnerability and its distribution across the clinical relationship. We suggest that researchers, policy makers, and clinicians need to think reflectively and critically about the ways in which we and our tools and interventions are influential in producing AOD problems, what constitutes progress, and ultimately what the focus of treatment should be.