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Article year 2007 the new abstentionists

The new abstentionists*Around Bonfire Night 2007 a rocket shook the peak of England’s drug treatment structure – someone askedhow many patients ended up drug-free. Clothless as the fabled emperor, 3% was the answer. Bullishengagement and crime reduction claims were dismissed as irrelevant. Scotland had already suffered a similarattack. The new abstentionists were on the march and the statistics seemed to be with them. But their attacksand the defences put up against them were based on questionable assumptions and misinterpreted or just plainmistaken figures. This forensic examination of the claims examines the good and not-so-good to emerge fromthis episode and finds some inspiration for the future. Mike Ashton is the editor of Drug and Alcohol Findings, a UK-based web service (http://findings.org.uk ) devoted to analysing evaluation of interventions to reduce drug or alcohol problems, but is writing here in a personal capacity. Hecan be contacted at mike.ashton@blueyonder.co.uk.
For variously their comments, assistance and encouragement, the author is grateful to: Daphne Obang, member of theexecutive of the Association of Directors of Adult Social Services; Harry Shapiro of DrugScope; Neil McKeganey ofthe Centre for Drug Misuse Research in Glasgow; Kazim Khan of T3E UK; Tim Millar of the National Drug EvidenceCentre in Manchester; Peter McDermott of The Alliance and an NTA board member; Richard Phillips of PhoenixFutures (who helped draft the document referred to in the text as from the leaders of the UK’s most influentialtreatment services); Ian Wardle and Maggie Rogan of the Lifeline Project; John Witton and John Strang of the NationalAddiction Centre; Sara McGrail, Freelance Drug Policy Specialist; Malcolm Roxburgh, Information Manager at theNational Treatment Agency for Substance Misuse; and David Clark of WIRED. It should not be assumed they werecommenting on behalf of any organisations with which they are affiliated or agree with any of the sentiments expressedin this text. Though they have enriched it, they bear no responsibility for the text nor for any remaining errors,misinterpretations or gaps.
This web publication retains the warts and unreconstructed referencing of the original draft. It ispresented as a stimulus to debate prior to print publication of a more refined version in Druglink,the magazine produced by DrugScope, Britain’s national drug misuse information service. Thatversion and later drafts of this version may feature comments received, which should be sent toharrys@drugscope.org.uk. This can be done by clicking the button below.
*For the avoidance of doubt, this title is not intended to embrace any particular individuals but to identify a tendency . In particular it should be clear from footnote 22 that it does not refer to the signatories to the document cited as reference 23. Towards the end of October 2007 the NTA’s1 crime-reduction justification for investing intreatment wilted before the BBC’s straightforward assumption that treating addiction ought to beabout getting people off drugs.2 Even after correcting the BBC’s mistakes,3 the NTA’s figuresshowed that in England just 3% of people in drug treatment in 2006/7 were recorded as havingcompleted treatment and left drug-free at the end of the year, confirming the substance of theBBC’s attack.
It was a blundering but in some ways welcome return to forefronting what I’d guess most peoplethink treatment should be about. However, there was some less welcome collateral damage. Thefocus on completing and leaving treatment was entirely contrary to recent research and expertopinion supporting ‘continuing care’ as the appropriate treatment model for many dependentsubstance users.4 5 That it continues indefinitely is a defining feature of methadone maintenance,placing it in the middle of the firing line.
A few months before, David Cameron’s New Conservatives had released the fruits of theiraddictions policy think tank. No barb was sharper than the claim that “maintenance methadoneprescribing which perpetuates addiction and dependency has been promoted under current policywhile rehabilitation treatment has been marginalised”. 6 Maintenance was further condemned as“undermin[ing] the efficacy of criminal justice treatment interventions”.
With sweeping disregard for evidence and accepted definitions, the treatment which across theworld has done most to curb addiction7 8 9 (leading to its designation by WHO as an “essentialmedicine”10) and with it almost certainly crime11 was portrayed as sustaining both; ally hadbecome enemy.
The solution? Among other things, the “radical reform” needed in treatment is “about facing thefact that abstinence is the most effective method of treatment.”12 This ‘fact’ takes some facingbecause the favoured settings were to be intensive day care and residential rehabilitation, neitherwith the solidity of the evidence base accrued by methadone.13 14 But to be fair, once theassumption is made that abstinence is the only goal really worth striving for, evidence isirrelevant; by definition, treatments which embody this objective are also the only ones really worthinvesting in.
Forsaking ‘harm reduction’, the Conservative advisers’ christened their new policy thrust “harmprevention” – coincidentally (or more probably, derivatively) the term also adopted by Australianabstentionists in their bare-knuckle word fight with compatriots who keep faith with harmreduction despite the federal government’s backsliding.
In Scotland, where the administration is said to be planning to urge drug users “to ditchmethadone and other softly-softly approaches in favour of ‘cold turkey’”,15 the polarisation has yetto reach these depths – but it’s getting there, prompting Holyrood’s former deputy justiceminister (also an addictions psychiatrist) to attack “the current anti-methadone direction of thedrugs debate in Scotland”.16 MSP and former Scottish health minister Susan Deacon was movedto warn that “the space for sensible and honest discussion seems to be inversely proportionate tothe size and complexity of the task”.17 Uncannily, the 3% figure also took centre stage there as the proportion of patients who remained “totally drug-free” 18 three years after starting methadone. According to a Sunday Times headline, itmeant the programmes “fail” the remaining 97%.19 But in all this debate, little was what it seemed. Contentions seemingly anchored in hard statisticsand solid research were at best questionable, at worst misleading and counterproductive.
Certainties are elusive largely because the best UK data we have on drug dependence treatment20still derives from the NTORS study in England, whose patients started those treatments overtwelve years ago. Still, we can plumb that data mine for clues to what might be happening todayand also call on fragments of more recent evidence.
The aim here is to raise issues most of which have no secure resolution and in the process toquestion the certainties we thought we had. Not to say, for example, that treatment doesn’t save usall money, but to question whether it has been shown that it does. If this prompts convincingreassurances that all really is well, so much the better.
Recovery returns look poor
The charge that Britain’s treatment system fails all but a few rests on the twin assumptions that
abstinence is the only acceptable goal, and that only by becoming drug-free can former patients
become, in The Independent’s words, “productive members of their community”.21
To a more nuanced degree,22 the second assumption is shared by the leaders of the UK’s mostinfluential treatment conglomerates and national NGOs: “What [methadone maintenance]treatment does not appear to do, however, is to provide a true exit from the interrelatedbehaviours, harms, risks and lifestyle norms associated with dependent drug use . MMT offersbetter life prospects than class A dependent drug use; it is equally true that abstinence offers betterlife prospects than MMT.”23 Given these twin assumptions, the returns from treatment look poor indeed. To the man orwoman on the omnibus, represented by the BBC’s home editor Mark Easton, the moreintangible benefits in the form of reduced crime fail to convince. Whatever else it does, iftreatment doesn’t put the patient back on their feet and if possible effect a cure, then it has a hardtime looking like ‘treatment’ at all.
Health minister Dawn Primarolo put up a defence indicative of a great deal of compassion andunderstanding of the difficulties faced by addicts in “rebuilding” devastated lives, speakingmovingly of “families in chaos” and decimated “social support networks”,24 but neither she northe NTA’s riposte25 fundamentally challenged the assumptions on which the BBC’s attack wasbased, leaving treatment vulnerable to further attacks on the same basis. We’ll test thoseassumptions one by one against the evidence and against alternative values.
Abstinence is good?
Though Brian Iddon (chair of the all-party Parliamentary Drugs Misuse Group) notably
demurred,26 other parties to the debate implicitly accepted abstinence as an unquestioned good,
the most desired goal if often a distant one. By ‘abstinence’ here, the BBC, the drugs field leaders,
and the NTA, all understood abstinence from legal medications substituting for illegal drugs, not
just abstinence from illegal drugs.
The single most important fact their contributions failed to stress is that getting opiate dependentpatients abstinent without putting sufficient (and perhaps very costly) investment in to anti-relapse rehabilitation is a very good way to help them kill themselves through loss of tolerance andoverdose. Let alone a poor quality of life, too many will have none at all.27 The death toll from opiate blocking treatment in Australia is perhaps the worst example. Post-detoxification patients trying to avoid relapse by taking naltrexone faced at least a 1 in a 100chance of dying within about three months, usually from opiate overdose in the weeks followingdrop-out or treatment termination. The true figure may have been as high as 8 in a 100, manytimes the risk associated with substitute prescribing.28 After this study, a doctor advising patientstempted to try this route to a drug-free (at least, opiate-free) life would, or should, have to warnthat some research indicates they face close to a 1 in 10 chance of being dead within threemonths.
In contrast, the fact that being (not having been) in methadone treatment saves lives is its clearestand most consistent benefit,29 demonstrated at a city-wide level recently in Barcelona. In the ’90sthe life expectancy of heroin users entering treatment there increased by 21 years, largely due tothe expansion of low threshold oral methadone maintenance programmes.30 Without theprotection afforded by methadone, and even though all the study’s subjects had entered specialistaddiction treatment of some kind, heroin users were seven times more likely to die.
Drug-free treatment completion equals success?
What of the majority who do survive? In the NTA’s figures these are the people recorded as
having completed treatment drug free.31 They are not in treatment and have not been referred on
for further treatment, yet without the continuing support of substitute drugs or a protected
environment, they have become drug-free. These surely are the success stories?
If they were, we would expect them not to burden the statisticians again or not for a long time,because a return to the statistics means a return to treatment, which means relapse to dependentdrug use. At the end of 2004/5 in England, 3626 individuals32 had completed treatment drug-freewithout having to return.33 But during that year there were 5759 drug-free, treatment-completeddischarges. So even within the same year, many drug-free discharges probably ended in relapseand return to treatment.34 But what of the 3% the BBC taunted the minister with, in 2006/7, the 5829 patients and clientswho completed treatment drug free and did make it through to the end of the year without havingto return? For a clue to their fate we have to turn to Cheshire and Merseyside, regions with an unusuallylong series of data compatible with the national monitoring system.35 At the end of 1998 about 6%of patients were recorded as having been discharged drug free after completing treatment. Ofthese, 57% returned over the next six years. Judging from this, their relapse rate was greater thanpeople who failed to complete their treatment, 54% of whom later returned. In the very next year,46% of the drug-free treatment completers in 2001/2 (last year for which data was presented)returned to treatment, just 3% fewer than the drop-outs.
For these regions at least, if by ‘successful’ we mean treatment which helps patients constructlives satisfying and stable enough to avoid relapse and further treatment, there is no evidence36 that drug-free completion is any more indicative of success than the ‘failure’ of premature drop-out. Using these as indicators of success or failure may be entirely to miss the point.
In Scotland the renewed focus on abstinence seemed justified by an impressive accounting of its“benefits” in that country’s own version of NTORS, the DORIS study.37 Three years afterentering treatment there were sometimes vast differences between the abstinent and non-abstinent in social integration (education/employment and crime), self-perceived health, andmental health in the form of suicide attempts or self-harm – and they all favoured abstinence. Itunderlined “the benefits for both the individual and the wider community of drug users having anextended period of abstinence,” concluded the researchers.
Set aside for the moment the criterion for abstinence (of which more below), the morefundamental issue is whether abstinence caused/enabled those other gains – as the term ‘benefits’implies – or whether it was the other way round, or some other causal configuration.
Abstinence was measured over the past three months, its ‘benefits’ over the past 17. Already oneessential ingredient for establishing causality is missing – that cause must be shown to comebefore effect. It seems just as conceivable that someone lucky or determined enough to land a jobor a training place or to overcome self-destructive impulses had enough stake in life to thenabandon illegal drug use – or as Professor McKeganey, the lead researcher suspects, a complexprocess in which abstinence reinforces life changes and vice versa.38 This is no nit-picking, but has important practice implications. For example, if abstinence isrequired for social reintegration then we should go for abstinence in our interventions and let therest follow. Aiming for social reintegration first would simply be a waste of time without afoundation of abstinence to build on. If it was the other way round, then we’d do better to focus atleast as much on social reintegration regardless of whether the individual was currently abstinent.
Just such a debate has been going on in the USA where ‘housing first’ advocates have tested theassumption that multiply problematic substance users39 need to be drug-free before they canbenefit from housing. The answers were that they don’t, and that providing housing first helpsthem reintegrate, stabilise and improve their quality of life even if they are not yet drug-free.40 Inother populations and other circumstances this might not be the case, but it does illustrate theunreliability of the ‘abstinence is essential’ assumption and the potential for counterproductivedenial of services when it is taken as gospel.
Patients want to become abstinent
The drive to reinstate abstinence as the kite mark of successful treatment is legitimised partly by
the claim that this is what the patients want, a respect for their desires which may have
something to do with them coinciding with those of the commentators. ‘If abstinence is what the
patients want, who are we to cold-water their ambitions?’ runs the argument, and it is a powerful
one with more than a grain of validity. But again, reality is more complex and less certain.
This particular argument kicked off when Scottish version of NTORS reported the “surprising”finding that 57% of patients opted for abstinence as their sole goal for changing their drug use. 41Stabilisation and harm reduction were further down the list. In fact, given the make-up of thesample it would have been surprising to find anything else: 44% were starting drug-free and/orexplicitly abstinence-based treatments and a similar proportion were in prison at the time including many who started in methadone.42 In both cases, abstinence would normally have beenthe only sensible objective.43 Still, even in methadone programmes, 43% endorsed abstinence as their sole objective, seeminglyat odds with their treatment – though perhaps not if that was methadone-based detoxification. It’salso the case that nearly 60% of methadone patients endorsed stabilisation and harm reductiongoals even if they also wanted to become drug-free.
But these are quibbles compared to the issue of exactly what the patients meant when they tickedthe “abstinence/drug free” option. The question was, “What changes in your drug use do youhope to achieve by coming to this agency?” Would patients just starting on methadone reallyinclude this medication among their ‘drug use’? If so, it begs the question of why some startedthis treatment if all they wanted was not to be on it. More plausibly, they meant the drugs causingthem trouble, not the medications helping overcome these. And if they did include methadoneamong their drug use, on what time scale did they want to abandon it? Straight away, or at sometime in the future when they were ready? No one knows.
What we do know is that over the next eight months 35%44 to 41%45 of the patients sustained eventwo weeks’ abstinence (from drugs other than cannabis) and that at the end of this period 15%46to 17%47 were not using. Most of the 57% who eight months before professed abstinence as theirsole goal had yet to get there. It seems a fair bet that had those on methadone been taken at theirword, and the assumption made that they meant ‘now’ rather than ‘when ready’, some wouldhave died in the attempt, come close to dying, and/or blighted their health and future prospectsthrough continued unsafe drug use and crime.
In England recently a rather more specific question was put to methadone patients.48 Asked abouttheir treatment goals, as many wanted to stay on their current dose or reduce as wanted to stop –and in this case the question was specifically about long-term goals. What if the question had beenabout starting to stop right now and ending drug-free in a couple of weeks time? The drift towards maintenance in supposedly methadone reduction programmes in NTORSseems to suggest ambivalence about such a proposition, and these were patients who on the faceof it had opted for reduction. In so far as reduction was implemented, outcomes were poorer.
“The more reductions in methadone that were given during treatment, the more likely thepatient was to be a regular heroin user at follow-up,” the sole treatment feature related to thisoutcome.49 Together these studies at most suggest that in the indeterminate long-term, a fair proportion ofmethadone patients would like not to have to take medication in order to sustain their recovery.
In this they are no different from patients taking other medications for long-term conditions,many of whom who feel uneasy about having to keep taking the pills even if this is clearly in theirinterests.50 Their wishes must not be ignored, and in any event it is their choice, but neither wouldit be responsible for doctors to simply say, ‘Go ahead, good for you. Why not tomorrow?’ However, all this is to focus too narrowly on substance use. What drives most patients to resort totreatment is not substance use as such, but the mess this combined with the way society respondsto it has made of their lives.51 Had they been asked and the results reported, we might have foundthat the patients’ priorities were getting out of debt, avoiding crime and prison, getting off thestreets, mending broken relationships, or improving health. In these senses, stabilisation andharm reduction might well have topped the list in the DORIS study.
3% drug-free in Scotland, 25% in England?
This startling comparison derived from research led by Professor Neil McKeganey, the academic
most closely associated with the abstentionist revival.52 His results appalled some Scottish
politicians and media commentators – just 3% of methadone patients abstinent three years after
starting treatment. Worse still for a nation newly emergent from Westminster’s thumb, the
English were doing better. There the corresponding figure was 25% after two years, complained
the Sunday Times53 and a news service read by Scotland’s top administrators and policymakers.54
It was a comparison they were invited to make by the researchers but one in which mistake waspiled on mistake. As far as can be told, the 3% figure derived from a paper published in 2006documenting the fate of 695 (all those who could be reinterviewed) out of 1033 drug users whohad started treatment in 2001 in Scotland.55 It is to date the most significant outcome report fromthe DORIS study, Scotland’s NTORS.
For the DORIS team anything other than drinking or smoking in the three months precedinginterviews conducted roughly three years after treatment entry meant the former patients werenot abstinent. Unlike NTORS, they opted to deny the abstinent label to anyone using cannabis orbeing prescribed legitimate substitute medication.
Curiously, someone could be ‘abstinent’ if they were drinking morn till night but not if they hadsmoked a joint once in the past three months. Nor could the criterion be made sense of asconfining ‘abstinence’ to legal drug use since it excluded legal opiate substitutes. These decisionswere justified by appeal to the abstinence objective endorsed by most of the sample, yet, as theresearchers had admitted,56 they had little idea what respondents meant when they ticked thisoption.
On this criterion, overall just 8%57 of the sample qualified as abstinent. Elsewhere in the paperwas the damning 3% figure, taken by press and politicians to mean that just 3% of the patientswho started methadone three years before had emerged abstinent. But in fact the 3% (aspublished, 3.4%) related to “post-index-agency” treatment, in other words, to patients who hadstarted methadone after leaving their first DORIS treatment. Nowhere does the paper tell us whathappened to people who started the study on methadone.
Already this invalidates the comparison with the 25% figure from England. More properlyrounded to 24%, this derives from the NTORS study and does relate to treatment starters.58 Therewere other major discrepancies. First, people who confined themselves to legally prescribedmethadone were embraced by NTORS’ abstinence outcomes. The DORIS researchers adjustedfor that, raising their estimate for abstinent (ex)methadone patients in Scotland to 11%, a factignored by the press reports.
For the DORIS team, that evened the playing field.59 Still the Scottish figures looked bad. But infact the field remained tilted, not just because of the post-index treatment issue explained above,but because NTORS ignored cannabis use. Given that this is the most pervasive of the illegal drugs,it could have made a substantial difference to the estimates, bringing the Scottish and Englishfigures much closer than they seemed. Clues to how much closer can be extracted from an earlier DORIS paper in which, for example, at the 16-month follow-up another 7% of the sample wouldhave been considered abstinent had cannabis been disregarded.60 The scare that just 3% of Scottish methadone patients reached abstinence nirvana compared to25% south of the border was based on error after error, and with it the panic that things must bebadly wrong and something radical done to even out the discrepancy.
Divert to residential rehabilitation? Despite that, it seems likely that abstinence as the DORIS team defined it was indeed rare aftermethadone, since these programmes were among the bag of non-residential rehabilitationcommunity services which ended in 6% abstinence. The contrast was stark with residentialrehabilitation, where the figure was 25%. Rather than the comparison with England, for theresearchers this was the key finding.61 Since they62 could divine little difference betweenmethadone and rehabilitation caseloads, the impression was that diverting more patients in toresidential rehabilitation would improve the nation’s abstinence outcomes and with them socialreintegration.
Some caution was to be expected here because, as the Scottish Executive itself was advised by oneof its reports, internationally the evidence for residential rehabilitation is weak compared tomethadone maintenance.63 After reviewing the evidence, England’s National Institute for Healthand Clinical Excellence could not be sure that residential rehabilitation led to any greater degree ofabstinence or drug use reduction than non-residential treatments.64 Wholesale diversion ofcurrent or would-be future methadone patients in to rehabs would be a leap into the gloom (if notentirely in to the dark) with people’s lives.
The view that nevertheless some diversion is warranted presumes that among the methadone-prescribed thousands are patients who, if only they were given the chance (or a big enough push),would do as well in rehabilitation as the few who currently make it through the doors. That maybe true, but very scarcity of rehabilitation entrants in Scotland gives rise to the suspicion that theyare either very unusual or unusually lucky in the support available from local services andpurchasers.
It seems likely that the hoops aspirants have to go through to secure funding for and admission toresidential care would screen out the people on whom this investment was most likely to bewasted, or who might undermine the therapeutic power of peer relations in these closedcommunities. This, after all, is one of the reasons for the assessments. Community-based servicesare expected to be less choosy and have fewer mechanisms for exerting choice over their patients.
For all these reasons, until proven otherwise, it is unsafe to assume that patients who wouldotherwise have started on methadone would do well if diverted to residential care, or indeed, viceversa. Similar considerations led the NTORS researchers to avoid direct comparisons of theperformances of the different treatment modalities in the study. These would be invalid unlessthere was a level playing field in terms of caseload and that simply could not be assured.65 Theother complication, one also (see below) applicable to DTORS, was that over the years patientsrarely confined themselves to a single treatment modality, complicating the assessment of justwhat it was which led to the final outcomes.
Plus ça changeThe more pragmatic of today’s advocates for rebalancing treatment towards residential rehabilitation argue that methadone’s prominence is partly due to the inaccessibility of the resources needed to help patients live without drugs, legal or illegal. They acknowledge that substitute prescribing will still be needed, but needed for fewer people if more had access to the 24-hour, 360-degree life-changing influences which can be provided in a residential setting.
At its most defensible the argument runs that if we had enough of the right kind of institutions, if they were attractive and easily and rapidly accessible, and if post-discharge anti-relapse supports were sufficiently prompt, accessible, attractive and robust, maintenance might wither to cater for the few who could not or would not take advantage of these offers.
Curiously, a very similar argument was put forward over 60 years ago by the Rolleston committee – to justify opiate maintenance prescribing. Effectively, but more elegantly, they argued that if only we had more accessible (in those days, that meant more affordable) rehabilitative institutions66 we might be able to withdraw most people and maintain few – but we haven’t, so needs must.67In both eras the argument may have some validity but remains to be proven because the infrastructure has yet to be put in place to be able to test it. Highlighting that gap – the apparent retreat from residential rehabilitation not just in Scotland but elsewhere in the UK – is one useful thing to emerge from this episode.
Caution is warranted not just by an international research record blighted by high drop-out rates, but also because here in the UK both DORIS and NTORS showed that even if everyone had access to residential rehabilitation, that wouldn’t eliminate the need for substitute prescribing. In Scotland it seems that most (perhaps 48) of the 85 residents who had already had the benefit of residential rehabilitation then had to be rescued from relapse by methadone treatment,68 and in England perhaps a third.69If in Scotland some of these then exited methadone drug-free, they could have accounted for a large proportion (after all, there were only 21) recorded as drug-free after having started DORIS in residential rehabilitation. Similarly we don’t know how many who emerged drug-free directly from rehab had previously been stabilised via methadone maintenance. Answers to these questions are needed before we can assume that the credit for the rehab ‘successes’ was not also Methadone is incompatible with a truly productive life?
Despite the risks (according to research, probability) of losing the stability gained on methadone
and of relapse with all its consequences, maybe the potential prize in terms of a truly productive,
socially integrated life makes it worth trying to do without the medication? Here we come across
the clearest fallacy in the current debate, the place where black turns white and vice versa – the
contention that only the drug- and in particular the methadone-free can achieve this
transformation.
Far from methadone impeding reintegration, depriving patients of this treatment is itself a veryeffective way to impede and reverse social reintegration.70 Where before long-term retention wasseen as a the main mechanism for the treatment’s effectiveness and a sign of its success, now it isbeing devalued as a failure to become drug-free.
Turn back to the ’60s and Dole and Nyswander’s original methadone maintenance study, andreintegration was very much not just the objective, but the core outcome and the selling pointfocused on by its creators.71 You don’t have to believe, as Vincent Dole did, that addiction is ametabolic disease to accept that some opiate dependent patients need to continue to take opiate-type medications precisely in order to function in ways which to them and to us look every bit as productive as the lives of many teetotallers or social drinkers. To focus on whether they are takingdrugs is to miss the point – it doesn’t matter, what matters is the quality of their lives and theircontributions to society.
In so far as this is hampered by their treatment, it could be because of the stigma we attach to itand the restrictions we place upon it which can preclude a normal family and working life. At itsmost basic, in English prescribing services provision outside normal office hours is often poor,72and here and elsewhere the demands of supervised consumption and regular attendance, and thefear of being exposed as a patient, risk a self-fulfilling prophecy.73 74 75 76 77 Even the drugs field itselfis ambivalent about employing drug users still in treatment.
Tarnishing the silver bullet
Opiate substitution is as close as we get to a silver bullet in addiction treatment. But in PR terms
in Britain, and to a degree in practice, its potential has been squandered. First was the unique
freedom British doctors had to prescribe injectables including injectable heroin, an option largely
abandoned here only to be picked up and validated in continental Europe.78
The oral methadone services left in the wake of this retreat have allowed themselves to concedethe reintegration ground to drug-free services – allowed themselves not to be seen as potentially aneffective platform for non-residential rehabilitation. This is partly because in reality they havefailed to realise this potential. Nationally the ambition has been titrated down to keeping patientsoff the streets and out of the courts, a poverty of ambition now rightly being challenged.
In NTORS, despite being in regular contact with a medical service, methadone patients’improvements in physical and psychological health were disappointing.79 Inputs to improveaspects of their lives other than those catered for by methadone itself seemed minimal – a weeklyhalf-hour one-to-one counselling session in the first month (and for a quarter none at all)dropping to about fortnightly after three months, and for a few, group counselling. 80 But more of the kind of counselling they received would not necessarily have improved things.
How much they got in the first month was unrelated to substance use at six months, and thosewho were counselled did no better on this measure than those left to get their support from othersources.81 Compared to primary care services, in the first month specialist clinics provided bothnearly twice the number and the length of counselling sessions, and continued to provide more,yet (see below) if anything outcomes were better at the surgeries.82 Probably around the time the NTORS patients were being treated, interviews with staff andpatients at London methadone services offered a rare glimpse of the dynamics behind thesestatistics.83 Therapeutic relationships were undermined because patients saw counsellors primarilyas gatekeepers to methadone, and by resource constraints which left time for little more thanmonitoring progress rather than counselling and support. Patients who feared that illegal druguse would meet with a disciplinary sanction and dose reduction reacted by withholdinginformation, creating distrust and tension and impeding even the ability to monitor progress andreact accordingly.
If it’s thought that the route forward is greater access to specialist treatment and greateradherence to good practice guidelines, findings from NTORS and elsewhere should give pausefor thought. Despite their specialisation, hospital bases, psychiatrist leads and multi-disciplinary teams, drug dependence clinics have not been shown to perform better than experienced andsupported GPs. In NTORS the GPs saw comparable patients but cut crime more rapidly andachieved greater improvements in psychological health and non-opiate drug use, and at each timepoint from one month to two year recorded slightly better retention (assuming that retention isgood and black and white have not yet been reversed).84 85 In Liverpool in the mid ’90s the health care contrast was in some respects stark. Primary caremethadone patients were several times more likely to have been tested for hepatitis B or hepatitisC and to have been immunised86 against hepatitis B than those at the specialist clinic, andretention at the primary care service seemed much better even taking into account caseloaddifferences.87 Surely things are better now?
Some things88 have got better since the NTORS patients started their treatments in the mid ’90s,
but in term of the abstinence and reintegration outcomes which came to the fore in October
2007, they may have as easily have got worse.
A few indicators can be extrapolated from NTORS itself. Compared to the primary care servicesrun by GPs, in that study the specialist clinics adhered more closely to what was and still is beingurged as good practice. Over the first six months, six of the eight clinics practised supervisedconsumption compared to one of the seven surgeries, daily dispensing was more common, andthey almost exclusively prescribed oral methadone while GPs occasionally prescribed thedeprecated methadone tablets or ampoules, which guidelines said should be reserved tospecialists.89 Yet (see above) the GPs did as well or better. Similarly, the GPs performed relativelywell despite offering even less counselling than the clinics, and counselling quantity was unrelatedto substance misuse outcomes.
Such findings raise a question mark over whether specialist staff and settings and counselling ofthe kind provided in the ’90s (and for all we know, today), and the guidelines promoted as goodpractice, really are indicators of good quality treatment, and whether further progress in thesedirections will make things better or worse for the patients.
They also suggest a way forward. As the authors of the Liverpool study commented, “It may bethat general practice provides a stable, more flexible and convenient setting, with the integrationof other aspects of health care”. Recent specialist training initiatives for GPs and the expansion ofshared care may be spreading these benefits, as long as increased standardisation and regulation isnot at the same time eroding the personalised care which may lie at the heart of their successes.
More recent findings from London methadone clinics and GP shared care services revealed a“relatively poor response to treatment”, a verdict delivered by authors which included staff of theservices concerned.90 When the services took a census of their patients in March 2003, typicallytheir patients had been in treatment for 14 months.
According to the information they gave to their keyworkers and recorded on forms completed bythose workers, they were now using heroin two to three times a week compared to daily at intake.
Even with respect to the drug targeted by the treatment it did not look good. It looked worsewhen the less manipulable evidence of urine tests was available – as expected, 84% opiate positive at intake, but on average over a year in to treatment still 60% positive.
Evidence that the punitive expectations of London methadone patients in the ’90s might not bemisplaced today comes from an NTA survey published in 2007.91 Mystifyingly, it was notuncommon for methadone services to ‘reward’ cessation of cocaine use by offering increaseddoses of opiate substitute medications or greater choice of the type of medication. The flip sidemust be that the unfortunates unable to curb their cocaine use were denied these aids torestraining their illicit opiate use.
Finally from 2004, a bleak account of the role of methadone from a bleak part of England, anorthern sink estate distinguished locally by an unenviable set of indicators of community andfamily breakdown.92 The report is based on in-situ interviews with 50 local problem drug users(on this estate, not hard to find), 31 of whom were in treatment, primarily methadone.
Most of the 50 had experienced school exclusion, three-quarters left without a formalqualification, marketable skills were rare, and a history of homelessness was the norm. All but sixwere unemployed even in the informal economy. Serious drug use had started early, for mostfollowing the example set by their parents. 60% had been in prison, though currently half weresteering clear of crime.
Overwhelmingly their comments on methadone were negative. Though some myth-swallowingwas evident, these are redolent of a treatment which most grudgingly tolerated for the partialrelief it gave from criminality and the hard grind of sourcing all one’s drugs illegally. To theauthors, the reason was obvious: “For many of our sample, the problem of methadone is in manyways that numbers of them actually do not wish to stop using heroin; hence the complaints aboutgetting an extra addiction.” Methadone is partly what you want to and, given all your other life circumstances, are able tomake of it. On the Trees estate it became sucked in to a polydrug repertoire which now cost lessas a result, but otherwise seems to have diminished not a jot .
Several years on, these it seemed were some of the faces of the “poor response” group inNTORS, the 1 in 6 methadone patients who a year after starting treatment continued with high-rate use of heroin and other illicit drugs.93 The other 5 in 6 (if that’s what it remains) either do notlive in such places or have better things to do than to associate with other drug users or hangaround the estate, the individuals most available to the researchers. Rather than being typical ofmethadone patients, they exemplify what the treatment’s role can become when the routes viawhich it could be used to construct a better life (which many wanted) seem closed off.
NTORS also supplied a finding which suggests that the recent influx of patients via the criminaljustice system might be making it harder to get good outcomes. This time the finding emergedfrom the residential services, mainly residential rehabilitation. After leaving, residents whorelapsed to regular heroin use were exactly twice as likely (56% versus 28%) to have enteredunder some form of criminal justice supervision or awaiting trial or sentence, the only pre-entryfeature distinguishing lapsers and relapsers from abstainers.94 A similar impression was gained in the north west of England in 2002 from patients entering tenspecialist opiate prescribing services.95 Six months later fewer than half were still there thoughanother 5% were said to have completed their treatments. Patients referred from the criminal justice system were nearly three times as likely to have prematurely terminated treatment. Inmethadone services, drop-out or throw-out usually means resumption of dependent opiate use.
Some contrary evidence comes from Kent where in 2003/04 structured day care services offeredsimilar treatments to court-ordered and ‘voluntary’ clients, and both did equally well.96 But in thisstudy only patients who stuck around long enough for the first interview on average three weeks97after treatment entry could be included, and many didn’t. With other attritions, the upshot wasthat less than half were recruited to the study and under 4 in 10 were interviewed at the firstfollow-up point.
Among this minority there were the (from NTORS) familiar reductions in crime and substanceuse but only “modest” improvements in physical or psychological health and none in access totraining or employment, though housing and relationships had improved. The authorsacknowledge that recruitment problems may have been one reason why their study gave adifferent impression to that obtained in the north west.
The most expensive and intensive way to try to transform dependent drug users in to sustainablydrug-free former users is residential rehabilitation, the modality which UK drugs field leaders sayis most suited to abstinence outcomes.98 In NTORS, one year after starting these programmes99 afurther 34% of drug users had achieved abstinence from illegal opiate-type drugs, stimulants andbenzodiazepines over the past three months.
However, 20% were once again in residential care. Despite the investment made in theirrehabilitation, perhaps just 1 in 7 were enabled to sustain abstinence out in the real world100 andsome (conceivably, every single one) of these will have had to enter methadone or othercommunity-based treatment programmes to avoid continued relapse.101 Of the heroin usersamong them, within a fortnight of leaving residential care half had returned to the drug.102 If the drugs field leaders who signed their recent joint statement are right, there is little if anyreason to believe things have improved and several reasons to believe they may have got worse.
Financial screws have been tightened and staff time has been diverted to institutional survival,while ill-informed commissioning and inadequate inspection regimes have been unable tosafeguard quality.
Apart from the Scottish DORIS study mentioned above, research on more recent performance isalmost completely lacking. One study of interest for this and for its criminal justice connectionsassessed how three DTTO teams in England in 2003 and 2004 handled their crack usingcaseloads.103 Two of the three sites could not even provide basic records. The third, in London,was able to provide case records for 70 relevant offenders, 48 of whom had undergone residentialrehabilitation.
Up to five of the 70 offenders may (we don't know – we only know the rest did not) havecompleted their court orders and remained free of crack or heroin use or heavy drinking. At thethree sites the inflexibility of the order and of the treatment providers combined with poor inter-agency working and administration to comprehensively fail the offenders enmeshed in theirsystems. We know that the early DTTO schemes suffered similarly;104 if these were teethingtroubles, at these sites they persisted in to maturity.
McDonaldisation lives on
Holistic, individualised care which addresses the debt, housing, relationship, vocational,
educational, legal and physical and mental health issues facing drug dependent patients is
predicated on holistic, individualised assessment and care planning. If you don’t know what
someone needs and wants, it’s hard to provide it.
When in 2005/06 the Healthcare Commission and the NTA investigated prescribing services inEngland, this was one of the weakest areas.105 Half the local drug partnerships (drug action teamsor the equivalent) and 4 in 10 services were “weak” in this respect. When it came to assessing andplanning for the risks facing the patients and their associates, the corresponding figures were 70%and 52%.
Some of the biggest gaps were extraordinary: a fifth of services not assessing overdose history, halfnot assessing for alcohol dependence, the same proportion for abscesses, another half notenquiring who else shared the home, and the biggest gap of all, 6 in 10 failing to assess risks oftransmission of blood borne viruses. With basic gaps like these, the chances of a holistic social aswell as medical assessment and care plan seem remote.
These figures were reached solely by looking at the services’ forms and documented procedures.
Conceivably, experienced and thorough practitioners actually did investigate all these issues andmore. Even then the failure to systematically prompt and document such assessments begsquestions. Perhaps more conceivably, despite the forms and procedures, assessments and planswere in practice sometimes missed or short-cut – as in US drug services where state-of-the-artpatient profiling measures mandated by the state were completed so those boxes could be ticked,but the results sat on shelves rather than informing service delivery.106 What the NTA took from the prescribing side of the data was that “There is a need to move awayfrom standard policies, which prescribe the same amount for each service user and for prescribingto be linked more closely to individual need”.107 If services are failing even in that core form ofindividualisation, the same seems at least as true in respect of the ‘ancillary’ wrap-around services.
Even when patients take the initiative and ask for help, they don’t always get it at the most basiclevel of a referral – in a survey of English drug service patients conducted in 2005, this applied toabout 4 in 10 each of those seeking housing or employment or training assistance and over halfseeking financial support.108 The respondents in this study were not a random sample – they wererecruited by the services themselves – opening up the possibility that these were the patients mostengaged with (and therefore most approachable and available to) the service.
What does this add up to? In the small parts where the veil has been lifted, a treatment ‘system’ inrespect of offenders sometimes hardly worthy of that term and across the board struggling tomove beyond crime and substance use reductions to effect the kinds of changes in people’s liveswhich could sustain their recovery. Despite questionable interpretations and prescriptions forchange, here is the grain of truth in the BBC’s accusations and the new abstinence lobby’s chargethat too little is being done to turn around the increasing numbers of lives touched by Britain’streatment system.
It’s not necessarily the fault of the providers. They have to follow where the targets and browniepoint tallies lead them or lose contracts, and they just don’t lead far beyond ‘Get ’em in and get’em out, treatment completed’. As long as the 31 December intervenes, a return in short ordercounts as just another successful patient recruitment.
In Germany the potentially self-defeating consequences of the drive for standardisation andefficiency in order to produce the required numbers has been analysed in a paper teasingly titled,“What do hamburgers and drug care have in common: some unorthodox remarks on theMcDonaldization and rationality of drug care”.109 The reader is challenged to read it and see if‘Germany’ could not be replaced with ‘Britain’ without invalidating the text.
At least society benefits from reduced crime?
Last of the shibboleths we’ll shake just a little is the biggest one of all, the one into which the
NTA poured nearly all its eggs and our money – the certainty that treatment saves us all money
by cutting crime. This finding from NTORS led the government to embrace treatment as the
single most effective tool within its grasp to cut national levels of acquisitive crime.
Though it did (deliberately past tense) the job in the sense of extracting money from the Treasury,this justification is now being publicly challenged as an inappropriate goal and insufficientoutcome for treatment. Such ethical misgivings might be derided as failing to grasp the hard-nosed reality of what it takes to prise open the public purse, but if at all, the argument stands uponly if it can be shown that crime really has been cut.
The queries aren’t about whether crime falls when dependent heroin or cocaine users entertreatment – on average, it does – but about whether treatment is the cause and whether thesechanges cumulate in to something which noticeably dents national crime levels and createseconomic savings.
At this level, the crime justification has no reliable evidence to back it up, resting on a degree ofcoincidence in trends in the crimes the government assumes are drug-related and theimplementation of the drug strategy’s treatment-based and criminal justice initiatives.110Knowledgeable commentators have pointed out that these crimes had been falling before thecurrent strategy started and probably continued to fall for reasons unrelated to levels of dependentsubstance use – and, by extension, for reasons unrelated to the numbers curbing their usethrough treatment.111 The crime most closely associated with addiction – shoplifting – has actuallybeen rising throughout the life of the drug strategy.112 The same commentators questioned the foundations for the drugs-crime link which underpinsthe strategy, based as it is on data from less than a quarter of the offenders unlucky enough to getarrested, a small fraction of all the active offenders in Britain.
Despite these caveats, some elements of Britain’s crime rate may have fallen less steeply had therenot been the investment in addiction treatment, but that’s the best we can say. In any event,crime reduction only ever justified treatment for a minority of the people who seek it – the 1 in 10patients in NTORS who were highly criminally active before treatment and among whomreductions in crime were concentrated.113 £3 crime cost savings for £1 treatment Still, it might be argued, a treatment net which captures these prolific offenders pays for itselfeven it also captures less troublesome patients. With its headline finding of £3 social cost savings(mainly due to reduced crime) for each £ spent on treatment, NTORS seemed to prove the case.
But both sides of the equation rested on assumptions seemingly so convenient for everyoneconcerned that their fragility has been overlooked.
Most people assume the £ was the full cost of the treatments studied in NTORS, but in fact itwas the extra amount spent on treatment in the year after entering the study compared to the yearbefore. This stroke-of-the-pen cuts the costs by nearly half but conflicts with the way otherstudies have done similar calculations.114 In some papers the NTORS team countenance thepossibility that prior treatments received by 80% of the sample had cumulated in to the benefitsharvested during the NTORS year,115 116 117 suggesting that these costs too would have to be added.
On the other side, the £3 consisted largely of costs to the victims of crime, which in turnconsisted largely of the value of stolen property.118 Effectively, the assumption was made that thesewere losses to society as a whole – yet some parts of society benefited in the form of cheap or freegoods. Some economists treat these as ‘transfer payments’119 and cancel them out when it comesto calculating the net loss to society. Because these were the proceeds of crime, NTORS decidednot to, inflating the cost-savings side of the equation.
What difference the alternative assumption would have made in NTORS we cannot know, butwe do know that in California disregarding such losses cut the cost savings to a third of theprevious estimate.120 This seminal study made this calculation precisely to reach an estimate of thereal costs to society as a whole, including its drug dependent members.
In Britain an economic analysis121 of the costs of methadone and buprenorphine maintenance, onwhich the National Institute for Health and Clinical Excellence based its guidance,122 triedexcluding victim costs to provide an alternative accounting of the benefits to society. It revealedthe “considerable impact that the inclusion of victim costs has on the results”, an impact whicheliminated the apparent advantage of treatment versus no treatment.
Add in the possibility that the crime careers of the NTORS patients had peaked before treatmententry and might have declined somewhat even without treatment, and it becomes highlyquestionable whether NTORS did demonstrate social cost savings from treatment. But a failure(if that’s what it was) to demonstrate benefits is not the same as there being none. Benefits therealmost certainly were in terms of saved and improved lives. These were not included in NTORS’economic estimates, leaving crime as the main component.
More with less
That brings us to the final problem – money. Per patient, resources for addiction treatment have
been cut and will probably continue to be cut.123 Getting more patients more quickly out the back
door of treatment is how the NTA hopes to square the circle of getting more in the front with
proportionately fewer resources.124
The problem is that keeping people on methadone is relatively cheap. To bring them to the pointwhere they can safely and sustainably do without it will not be. Turning round lives often blightedby severe psychological problems and a disastrous history stretching back to childhood, reversingthe deficits accrued during a decade or more devoted to dependent drug use, transformingenvironments which are more addiction- than recovery-friendly, and getting the rest of society tocooperate – that costs.
The risk is that this difficult and expensive work will not be done or will be short-changed. Inorder to meet the new expectations about ‘successful’ treatment completion, people may be led toexit treatment only to come back sooner rather than later because their lives have not fundamentally altered for the better, or exit more finally via overdose and disease. Already someservices have assumed that their mission now is to keep people for 12 weeks then get them out assoon as possible as a treatment completion or referral on, the criteria for success they think isbeing set from the centre.
Lives are being turned round, but to make this the norm will take special people who can forgeand stick with relationships which instil optimism and confidence, and a preparedness to go wellbeyond treatment to (among other things) low caseload, intensive case management, supportedhousing and supported employment, intensive and assertive outreach teams, persistent and activeaftercare, and reconstruction of family relationships.
Another way to square the more-for-less circle is to provide these inputs by accessing andbenefiting from generic welfare, housing and reintegration resources.125 In a resistant or resource-starved environment, this hasn’t always been shown to produce dividends.126 Assuming that theservices the most disadvantaged patients need will be provided through partnerships with otheragencies, yet still be accessed by and effectively delivered to drug users whose lives are in a messand unappealing fodder for the average housing department or apprenticeship scheme, is at worstunrealistic, at best a long-term solution to the cash squeeze. Equity and economy demand that theattempt be made and it certainly can succeed, but making these attempts is also an intensive andcostly business.
First stop making things worse
Arguably the most important things we can do cost little or nothing and may actually save money,
yet are the hardest to achieve. Rather than spending money to make things better, we can stop
acting and spending in ways which makes things worse, the link Dawn Primarolo failed to make.
Stigma and discrimination due to drug use contribute to poor health and psychological damage
and make people unwilling to come out and seek help until things are so bad they can’t carry on.
127 128 129 At this point the route back may be so steep that maintenance and harm reduction are the
only feasible options. Even the prisoners in our jails feel the added stigma of being known as an
‘addict’, the main reason in one sample why they did not seek help.130
Criminalisation, imprisonment and stigma tear apart the family and social ties and destroy theopportunities for decent housing and employment131 which could be clung to as anchors to helppeople haul themselves out of a bad patch with drugs. The few of these recovery resourcesdependent drug users may have started with are systematically dismantled by the same statewhich then tries to mitigate the damage. As Italian addiction psychiatrist Umberto Nizzoli put it,‘the doors are closed behind them’,132 blocking the way back to conventional ties and rewards andhelping to create the ‘chronic relapsing’ condition we find so hard to reverse.133 Can we change?
One way to make sense of all this is to see addiction not as something inside the patient’s head,
but as a relationship between them and the world around them, a two-way process as much in our heads and hearts as theirs. The implication is that we can overcome their dependence by changing the world around them sufficiently radically and persistently and in the right ways.
Their social world is a large part of that environment and the most formative, and the one over which we all have some degree of control. Rather than messing in their heads with chemicals and reprograming neurones through cognitive-behavioural strategies or Skinnerian contingencies, we can mess within our own, reprogram how we and the world we control relates to them, and get similar and perhaps more lasting results. When the worlds as a whole is recalcitrant, we can do this by sectioning off a bit in the form a residential centre and radically altering the environment within, but the results are vulnerable on return.
Though their promoters may not realise it or articulate it, this is the basis for the new found enthusiasm for residential care and wrap-around services as vehicles for more comprehensively altering how the world around them relates to the patients and residents.
It seems to be a lesson never learnt once and for all but continually rediscovered. One inspiring tutorial was played out in the late 1950s at the alcohol clinic of the Massachusetts General Hospital, then run by Morris Chafetz, later to become founding director of the US National Institute on Alcohol Abuse and Alcoholism.134He suspected that pessimism about whether alcoholics would accept and benefit from treatment derived partly from the dismissive and hostile attitudes of the broader society, including the very staff supposed to be helping them. If these were replaced by optimism and respect, patients might embrace the help they needed, and the grounds for pessimism might evaporate. He was right. Dr Chafetz showed that not only can a service’s performance be improved, it can be transformed by the simple application of empathy and organisation.
It seems simple but in fact it’s difficult because it requires people who in the first place care enough to try, have the imagination and empathy to put themselves in the seemingly alien shoes of the ‘the addict’, organisations supportive of their visions, and the clout and drive to beat steeply stacked odds to make these a reality.
In my experience Britain has an abundance of just such people working in its drug treatment sector. Many have come across from or still occupy the other side of the treatment table. Over the past 30 years I’ve been struck by the creativity, groundedness, and practical compassion of people doing a job most of us couldn’t get to the starting blocks with. Those were and still are the kind of people drawn to working with the multiply excluded and widely despised. Give them the right systems and the right environment to work with, and they will help create transformations, just as Morris Chafetz did.
They also need a society accommodating enough to be able to persuaded to embrace dependent drug users not just within its ghettoised addiction treatment centres, but in the rest of its service provision and social life – and this when some of the makings of a recovery-friendly environment are in short supply not just for drug users, but for everyone.
Top among them in Britain are decent affordable housing and economically and psychologically rewarding work as routes for people to emerge from welfare dependency despite extensive and intensive disadvantage. Many need treatment in the form of methadone, but as much or more they need housing where not everyone uses drugs, and jobs which give a modicum of self-respect and pay enough to make it worth jeopardising unemployed or disabled statuses.135When we just can’t manage to change in all these ways, we can at least radically alter one aspect of the drug user’s social environment – we can give them the drugs they previously had to source by relating to criminal circles and devote their lives to finding by hook or by crook, and offer them a socially accepted role as patient rather than junkie criminal.
This is a massive shift in itself but sometimes an incomplete one because they remain stigmatised, excluded from the mainstream and crippled by the obligations placed upon them. But at least we can do it and do it and do it en masse. And some (we should help to make it more) grasp this and create lives which contribute to society in ways those of us who get by on a drip feed of alcohol or nicotine or nothing at all should envy.
1 National Treatment Agency for Substance Misuse, the health service body responsible for advancing addiction treatment in England.
2http://news.bbc.co.uk/1/hi/uk/7068572.stm accessed 30 October 2007.
3 Hayes P. Drug treatment in England and the BBC. http://www.nta.nhs.uk accessed 4 November 2007.
4 Humphreys K. et al. “Toward more responsive and effective intervention systems for alcohol-related problems.” Addiction: 2002 97, p. 126–140.
5 McLellan A.T. “Have we evaluated addiction treatment correctly? Implications from a chronic care perspective.” Addiction: 2002, 97, p. 249–252.
6 Gyngell G. Breakthrough Britain. Ending the costs of social breakdown. Volume 4: addictions. Policy recommendations to the Conservative Party. Social Justice Policy Group, 2007.
7 Proposal for the inclusion of methadone in the WHO model list of essential medicines. World Health Organization, 2004.
8 Mattick R.P. et al. “Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence (Cochrane Review).” In: The Cochrane Library, Issue 4, 2002. Oxford: Update Software.
9 Simoens S. et al. The effectiveness of treatment for opiate dependent drug users: an international systematic review of the evidence. Scottish Executive Effective Interventions Unit, 2002.
10 Essential medicines. WHO model list 14th edition. World Health Organization, March 2005.
11 Ashton M. “Force in the sunshine state.” Drug and Alcohol Findings: 2000, issue 4.
http://findings.org.uk/count/downloads/download.php?file=Ashton_M_25.pdf.
12 In this strange formulation abstinence has become a treatment modality not a treatment goal.
13 Simoens S. et al. The effectiveness of treatment for opiate dependent drug users: an international systematic review of the evidence. Scottish Executive Effective Interventions Unit, 2002.
14 Drug misuse: psychosocial interventions. National Clinical Practice Guideline Number 51. National Collaborating Centre for Mental Health, 2007.
15 Barnes E. “Cold turkey plan for Scots addicts.” Scotland on Sunday: 17 December 2006.
16 Professor Richard Simpson, Holyrood magazine, March 2007.
17 Deacon S. “The political addiction to tough talking on drugs has failed us all.” Sunday Herald: 14 January 2007.
18 Barnes E. “Cold turkey plan for Scots addicts.” Scotland on Sunday: 17 December 2006.
19 Womersley T. “Methadone programme fails 97% of heroin addicts.” Sunday Times: 29 October, 2006.
20 Until the Scottish NTORS, DORIS, fully discharges its outcome data and the English follow-up to NTORS DTORS starts to produce data. See http://www.gla.ac.uk/centres/drugmisuse/DORIS.html and http://www.dtors.org.uk/DTORSHome.aspx respectivly.
21 Michael Savage. “The big question: are drug treatment programmes a waste of taxpayers’ money?” The Independent: 31 October 2007.
22 They were careful not to in any way condemn methadone maintenance or to fail to acknowledge the benefits and continuing need for such services.
23 Residential Rehabilitation and the national drug strategy. 19 October 2007.
http://www.phoenix-futures.org.uk/Filestore/Downloads/Residential_Rehabilitation_and_national_drug_strategy.pdf24 Radio 4 Today programme 18 October 2007, http://www.bbc.co.uk/radio4/today/listenagain/zthursday_20071018.shtml.
25 Hayes P. Drug treatment in England and the BBC. http://www.nta.nhs.uk accessed 4 November 2007.
26 Michael Savage, op cit.
27 Best D. et al. “Overdosing on opiates part I: causes.” Drug and Alcohol Findings: 2000, issue 4.
http://findings.org.uk/count/downloads/download.php?file=Best_D_17.pdf.
28 Gibson A. et al. Mortality related to naltrexone in the treatment of opioid dependence: a comparative analysis. NDARC Technical Report 229. [Australian] National Drug and Alcohol Research Centre, 2005. Summary at http://ndarc.med.unsw.edu.au, full report from NDARC, University of New South Wales, Sydney NSW 2052, Australia.
29 Best D. et al. “Overdosing on opiates part I: causes.” Drug and Alcohol Findings: 2000, issue 4.
http://findings.org.uk/count/downloads/download.php?file=Best_D_17.pdf.
30 Brugal M.T. et al. “Evaluating the impact of methadone maintenance programmes on mortality due to overdose andAIDS in a cohort of heroin users in Spain.” Addiction: 2005, 100, p. 981–989.
31 Scott G. Core data set reference data. NTA and NDTMS, 2007.
http://www.nta.nhs.uk/areas/NDTMS/docs/core%20data%20set/ndtms_core_data_set_reference_data_v4.6.pdf32 Note that within a year one individual can have several discharges.
33 Statistics from the National Drug Treatment Monitoring System (NDTMS) 1 April 2004–31 March 2005. National Treatment Agency for Substance Misuse, 2006.
34 Part of the difference between these figures represents an unknown number (according to an NTA source, a “fair proportion”) of concurrent treatment episodes each ending with drug-free completion rather than a return to treatment, making it impossible to be precise.
35 Beynon C.M. et al. “Trends in drop out, drug free discharge and rates of re-presentation: a retrospective cohort study of drug treatment clients in the North West of England.” BMC Public Health: 2006, 6:20.
http://www.biomedcentral.com/1471-2458/6/20536 We cannot know for sure because this extrapolation depends on the unevidenced assumption that the treatment completers were no more likely to return to treatment after relapse than the drop-outs. It is possible that, for example, the drop-outs relapsed at twice the rate but in proportion only half as many reacted to that relapse by returning to treatment. Also the treatment sequences may have differed in important ways. A drug-free discharge to residential rehabilitation may be indicative of good progress but not a return to a detoxification service.
37 McKeganey N. et al. “Abstinence and drug abuse treatment: results from the Drug Outcome Research in Scotland study.” Drugs: Education, Prevention & Policy: 2006, 13(6), p. 537–550.
38 Personal communication from Professor Neil McKeganey, 19 November 2007.
39 Typically dually diagnosed and in unstable or no accommodation.
40 See for example Gulcur L. et al. “Housing, hospitalization, and cost outcomes for homeless individuals with psychiatric disabilities participating in continuum of care and housing first programmes.” Journal of Community & Applied Social Psychology: 2003, 13, p. 171–186.
41 McKeganey N. et al. “What are drug users looking for when they contact drug services: abstinence or harm reduction?” Drugs: Education, Prevention & Policy: 2004, 11(5), p. 423–435.
42 Neale J. et al. “Comparing community and prison-based drug treatments.” Drugs: Education, Prevention & Policy: 2004, 11(3), p. 213–228.
43 Scottish Prison Service. Partnership and coordination. SPS action on drugs. Revised guidance on the management of drug misuse in Scotland's prisons. 2000.
44 A lower bound assuming all patients not re-interviewed were also not abstinent. It seems unlikely that more were abstinent than among the reinterviewed sample. Calculated as 30% all drugs + 11% cannabis only = 352 of 859 respondents = 35% of the 1007 baseline sample.
45 The proportion of the followed up sample.
46 A lower bound assuming all patients not re-interviewed were also not abstinent. It seems unlikely that more were abstinent than among the reinterviewed sample. Calculated as 11% all drugs + 6% cannabis only = 146 of 859 respondents = 15% of the 1007 baseline sample.
47 The proportion of the followed up sample.
48 Best D. et al. The NTA’s 2005 survey of user satisfaction in England. National Treatment Agency for Substance Misuse, 2007.
49 Gossop M. et al. “Outcomes after methadone maintenance and methadone reduction treatments: two-year follow-up results from the National Treatment Outcome Research Study.” Drug and Alcohol Dependence: 2001, 62, p. 255–264.
50 Holt M. “Agency and dependency within treatment: drug treatment clients negotiating methadone and antidepressants.” Social Science & Medicine: 2007, 64, 1937–1947.
51 See for example Marlatt A. et al. “Help-seeking by substance abusers: the role of harm reduction and behavioral-economic approaches to facilitate treatment entry and retention” In: Onken L.S. et al, eds. Beyond the therapeutic alliance: keeping the drug-dependent individual in treatment. NIDA Research Monograph 165. US Department of Health and Human Services, 1997.
52 Though it would be wrong to pigeonhole him in this category. His support also stretches to the what many will consider the very far end of the harm reduction spectrum – safer injecting rooms.
53 Womersley T. “Methadone programme fails 97% of heroin addicts.” Sunday Times: 29 October, 2006.
54 Executive to revamp drug policy. 4th December 2006. http://www.holyrood.com/home.aspx, accessed 5 December 2006.
Mistakenly this report said the figure related to Wales as well as England.
55 McKeganey N. et al. “Abstinence and drug abuse treatment: results from the Drug Outcome Research in Scotland study.” Drugs: Education, Prevention & Policy: 2006, 13(6), p. 537–550.
56 McKeganey N. et al. “What are drug users looking for when they contact drug services: abstinence or harm reduction?” Drugs: Education, Prevention & Policy: 2004, 11(5), p. 423–435.
57 And probably fewer of the full sample given the numbers not followed up. This applies to all subsequent figures.
58 Gossop M. et al. “The National Treatment Outcome Study (NTORS): 4–5 year follow-up results.” Addiction: 2003, 98., p. 291–303.
59 “If we had defined abstinence in the same way as the NTORS researchers (to include the use of prescribed methadone) …”60 McKeganey N. et al. “What are drug users looking for when they contact drug services: abstinence or harm reduction?” Drugs: Education, Prevention & Policy: 2004, 11(5), p. 423–435.
61 Personal communication from Professor Neil McKeganey, 19 November 2007.
62 Personal communication from Professor Neil McKeganey 13 November 2007.
63 Simoens S. et al. The effectiveness of treatment for opiate dependent drug users: an international systematic review of the evidence. Scottish Executive Effective Interventions Unit, 2002.
64 Drug misuse: psychosocial interventions. National Clinical Practice Guideline Number 51. National Collaborating Centre for Mental Health, 2007.
65 Gossop M. et al. “The National Treatment Outcome Research Study in the United Kingdom: six-month follow-up outcomes.” Psychology of Addictive Behaviors: 1997, 11 (4), p.324–337.
66 And they also said, the power to detain people in them.
67 Ashton M. “The Rolleston legacy.” Drug and Alcohol Findings: 2006, issue 15.
http://findings.org.uk/count/downloads/download.php?file=Ashton_M_28.pdf68 This seems to be the implication of table III.
69 Gossop M., et al. NTORS at one year. The National Treatment Outcome Research Study. Changes in substance use, health and criminal behaviours at one year after intake. Department of Health, 1998.
70 See for example: Winick C. “A mandatory short-term methadone-to-abstinence program in New York City.” Mount Sinai Journal of Medicine: 68 (1), 2001, p.41-45; Knight K.R. et al. "Involuntary versus voluntary detoxification from methadone maintenance treatment: the importance of choice." Addiction Research: 1996, 3(4), p 351–362.
71 Ashton M. “Methadone maintenance: the original.” Drug and Alcohol Findings: 2006, issue 14.
http://findings.org.uk/count/downloads/download.php?file=Ashton_M_26.pdf72 Healthcare Commission and National Treatment Agency for Substance Misuse. Improving services for substance misuse: a joint review. Commission for Healthcare Audit and Inspection, 2006.
http://www.nta.nhs.uk/areas/standards_and_inspections/documents/Joint_review%20full_report_0506.pdf.
73 Stone E. et al. “User views on supervised methadone consumption.” Addiction Biology: 2003, 8, p. 45–48.
74 Cox G. et al. “Maintaining or enabling? Evaluation of a methadone prescribing service in Dublin City.” In: Pieces of the jigsaw: six reports addressing homelessness and drug use in Ireland. Dublin: Merchants Quay, 2004.
75 Quaglio G. et al. “Patients in long-term maintenance therapy for drug use in Italy: analysis of some parameters of social integration and serological status for infectious diseases in a cohort of 1091 patients.” BMC Public Health: 6, 2006.
76 Smith I. et al. The estate they’re in. Trafford: The Edge, 2004.
77 Fraser S. “The chronotope of the queue: methadone maintenance treatment and the production of time, space and subjects.” International Journal of Drug Policy: 2006, 17(3), p. 192–202.
78 Ashton M. “Role reversal.” Drug and Alcohol Findings: 2003, issue 9.
http://findings.org.uk/count/downloads/download.php?file=Ashton_M_22.pdf79 Gossop M. et al. NTORS at one year. The National Treatment Outcome Research Study. Changes in substance use, health and criminal behaviours at one year after intake. Department of Health, 1998.
80 Gossop M. et al. "Treatment process components and heroin use outcome among methadone patients." Drug and Alcohol Dependence: 2003, 71(1), p. 93–102.
81 Gossop M. et al. "Effectiveness of drug and alcohol counselling during methadone treatment: content, frequency, and duration of counselling and association with substance use outcomes." Addiction: 2006, 101, p. 404–412. Though when, as most did, the sessions focused on drug use, cocaine and heroin use fell slightly more compared to non-counselled patients.
82 Gossop M. et al. "Methadone treatment for opiate dependent patients in general practice and specialist clinic settings: outcomes at 2-year follow-up." Journal of Substance Abuse Treatment: 2003, 24(4), p. 313–321.
83 Lilly R. et al. “Juggling multiple roles: staff and client perceptions of key worker roles and the constraints on delivering counselling and support services in methadone treatment.” Addiction Research: 1999, 7(4), p. 267–289.
84 Gossop M. et al. “Methadone treatment practices and outcome for opiate addicts treated in drug clinics and in general practice: results from the National Treatment Outcome Research Study.” British Journal of General Practice: 1999, 49, p.
31–34.
85 Gossop M. et al. “Methadone treatment for opiate dependent patients in general practice and specialist clinic settings: outcomes at 2-year follow-up.” Journal of Substance Abuse Treatment: 2003, 24(4), p. 313–321.
86 Or to be naturally immune.
87 Lewis D. et al. “General practice or drug clinic for methadone maintenance? A controlled comparison of treatment outcomes.” International Journal of Drug Policy: 2001, 12, p. 81–89.
88 Such as numbers of problem drug users in treatment (and possibly the proportion too, though this is unclear) and short-term retention.
89 Department of Health [etc]. Drug misuse and dependence – guidelines on clinical management. HMSO, 1999.
90 Dunn J. et al. “Notes from practice: Methadone prescribing in north central London – doses, compliance, goals and treatment setting.” Drugs: education, prevention and policy: 2007; 14(2), p. 181–191.
91 Weaver T. et al. Are contingency management principles being implemented in drug treatment in England? National Treatment http://www.nta.nhs.uk/publications/documents/nta_rb33_contingency_management_summary.pdf92 Smith I. et al. The estate they’re in. Trafford: The Edge, 2004.
93 Gossop M. et al. "Patterns of improvement after methadone treatment: 1 year follow-up results from the National Treatment Outcome Research Study (NTORS).” Drug and Alcohol Dependence: 2000, 60, p.:275–286.
94 Gossop M. et al. "Factors associated with abstinence, lapse or relapse to heroin use after residential treatment: protective effect of coping responses." Addiction: 2002, 97, p. 1259–1267.
95 Millar T. et al. Treatment effectiveness: demonstration analysis of treatment surveillance data about treatment completion and retention.
National Treatment Agency for Substance Misuse, 2004.
96 McSweeney T. et al. The quasi-compulsory treatment of drug-dependent offenders in Europe: UK findings. Institute for Criminal Policy Research and European Institute of Social Services, 2006.
97 Stevens A. T. et al. The quasi-compulsory treatment of drug-dependent offenders in Europe. Final national reportEngland. Institute for Criminal Policy Research and European Institute of Social Services, 2006.
98 Residential Rehabilitation and the national drug strategy. 19 October 2007.
99 Unfortunately the study conflated inpatient and residential rehabilitation programmes though over 70% of the residential sample came from the latter.
100 “British residential drug treatment services respond well to the stimulant boom but could do better if clients stayed longer” Background text for Nugget 4.7, Drug and Alcohol Findings: 2000.
http://findings.org.uk/count/downloads/download.php?file=nug_4_7_back.doc.
101 Gossop M., et al. NTORS at one year. The National Treatment Outcome Research Study. Changes in substance use, health and criminal behaviours at one year after intake. Department of Health, 1998. Over a third of former residential care patients were in community-based (which includes or may entirely consist of methadone) programmes one year after starting their residential treatment.
102 Gossop M. et al. "Factors associated with abstinence, lapse or relapse to heroin use after residential treatment: protective effect of coping responses." Addiction: 2002, 97, p. 1259–1267.
103 Turnbull P. J et al. Supervising crack-using offenders on drug treatment and testing orders. National Treatment Agency for Substance Misuse, 2007. http://www.nta.nhs.uk/publications/documents/nta_rb22_crack_users_dttos.pdf104 Ashton M. “First test for the DTTO.” Drug and Alcohol Findings: 2001, issue 6.
http://findings.org.uk/count/downloads/download.php?file=Ashton_M_23.pdf105 Healthcare Commission and National Treatment Agency for Substance Misuse. Improving services for substance misuse: a joint review. Commission for Healthcare Audit and Inspection, 2006.
http://www.nta.nhs.uk/areas/standards_and_inspections/documents/Joint_review%20full_report_0506.pdf.
106 Gurel O. et al. “Developing CASPAR: a computer-assisted system for patient assessment and referral.” Journal of Substance Abuse Treatment: 2005, 28(3), p. 281–289.
107 http://www.nta.nhs.uk/areas/standards_and_inspections/2005-06_review/key_messages.aspx accessed 15 November 2007.
108 Best D. et al. The NTA’s 2005 survey of user satisfaction in England. National Treatment Agency for Substance Misuse, 2007.
www.nta.nhs.uk.
109 Kemmesies U.E. “What do hamburgers and drug care have in common: some unorthodox remarks on the McDonaldization and rationality of drug care.” Journal of Drug Issues: 2002, p. 689-708.
110 Drug strategy fact booklets. UK government, 2007. http://drugs.homeoffice.gov.uk/publication-search/drug- strategy/strategy-facts-booklet?view=Standard&pubID=237897111 Reuter P. et al. An analysis of UK drug policy. UK Drug Policy Commission, 2007.
http://www.ukdrugpolicycommission.org.uk/docs/UKDPC%20drug%20policy%20review.pdf.
112 BRC Retail Crime Survey 2006/7. London: British Retail Consortium, 2007.
113 A Ashton M. “NTORS.” Drug and Alcohol Findings: 1999, issue 2.
http://findings.org.uk/count/downloads/download.php?file=Ashton_M_12.pdf114 Ashton M. “NTORS.” Drug and Alcohol Findings: 1999, issue 2.
http://findings.org.uk/count/downloads/download.php?file=Ashton_M_12.pdf115 Stewart D. et al. “Methadone treatment: outcomes and variation in treatment response within NTORS.” In: Tober G.S., et al. Methadone matters: evolving community methadone treatment of opiate addiction. London: Martin Dunitz, 2003. p. 249– 258.
116 Gossop M. et al. “Patterns of improvement after methadone treatment: 1 year follow-up results from the National Treatment Outcome Research Study (NTORS).” Drug and Alcohol Dependence: 2000, 60, p.:275–286.
117 Gossop M. et al. NTORS at one year. The National Treatment Outcome Research Study. Changes in substance use, health and criminal behaviours at one year after intake. Department of Health, 1998.
118 Godfrey C. et al. “Economic analysis of costs and consequences of the treatment of drug misuse: 2-year outcome data from the National Treatment Outcome Research Study (NTORS).” Addiction: 2004, 99, p. 697-707.
119 Simoens S. et al. “Pharmaco-economics of community maintenance for opiate dependence: a review of evidence and methodology.” Drug and Alcohol Dependence: 2006, 84(1), p. 28–39.
120 Gerstein D.R. et al. Evaluating recovery services: the California drug and alcohol treatment assessment (CALDATA). California Department of Alcohol and Drug Programs, 1994.
121 Connock M. et al. “Methadone and buprenorphine for the management of opioid dependence: a systematic review and economic evaluation.” Health Technol Assess: 2007;11(9).
122 Methadone and buprenorphine for the management of opioid dependence. NICE technology appraisal guidance 114. [UK] National Institute for Health and Clinical Excellence, 2007.
123 Ashton M. “NTA strategy: raising expectations, but heading for a funding crisis.” Drink and Drugs News: September 2005.
124 National Treatment Agency for Substance Misuse. Board meeting 4 May 2005. Treatment Effectiveness Strategy. “Moving people through and out of treatment also improves the efficiency of local treatment systems enabling the system to engage with newly presenting clients without having continually to expand capacity.”125 Klee H. et al. Employing drug users: individual and systemic barriers to rehabilitation. Joseph Rowntree Foundation 2002.
www.jrf.org.uk126 Vanderplasschen W. et al. “Effectiveness of different models of case management for substance abusing populations.” Journal of Psychoactive Drugs: 2007, 39 (1).
127 Ahern J. et al. “Stigma, discrimination and the health of illicit drug users.” Drug and Alcohol Dependence: 2007, 88, p. 188– 196.
128 Smith I. et al. The estate they’re in. Trafford: The Edge, 2004.
129 Young M. et al. “Interpersonal discrimination and the health of illicit drug users.” American Journal of Drug and Alcohol Abuse: 2005, 31(3), p. 371–391.
130 Fountain J. et al. The delivery of prison drug services in England and Wales, with a focus on black and minority ethnic prisoners.
Preston: Centre for Ethnicity and Health, 2004.
131 Klee H. et al. Employing drug users: individual and systemic barriers to rehabilitation. Joseph Rowntree Foundation 2002.
www.jrf.org.uk132 An eye-opening description which I first heard used by Professor Umberto Nizzoli of the drug dependence service in Reggio Emilia in Italy at a seminar organised by T3E (UK).
133 Ashton M. Burgered: quality of life and addiction treatment. Unpublished, available on request from the author.
134 Ashton M. “The power of the welcoming reminder.” Drug and Alcohol Findings: 2004, issue 11.
http://findings.org.uk/count/downloads/download.php?file=Ashton_M_29.pdf135 Smith I. et al. The estate they’re in. Trafford: The Edge, 2004.

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