Treatment reform in the U.K.

A direct challenge to the U.K. reliance on methadone.

I find it pretty easy to imagine similar circumstances in the U.S. if it weren’t for the numbers of recovering people already in the field and the good fortune to have high profile recovery advocates like Senator Harold Hughes and Betty Ford in the right place at the right time.

Another article deconstructs the U.K.’s definition of recovery and offers some context.

In particular, the inclusion of “sustained control over substance use”:

…in talking about voluntary exercised control there is a sense in which the thorny issue of drug user abstinence has been effectively sidestepped. But how is control in this context being defined? Does this definition mean that an individual continuing to use illegal drugs but in a more controlled way can be considered ‘in recovery’? Does it matter in terms of evaluating the effect of services if that element of control cannot actually be defined or measured? Does it matter if, as a result of this definition of recovery, we will not know whether the control that is being exercised is increasing, decreasing, or remaining the same over different lengths of time in treatment?

Aside from the difficulty of measuring the element of control, there is also the question of whose definition of control is going to apply in assessing whether the individual is indeed in more or less control of his or her drug use – that of the drug user, the doctor, or the addict’s family? Also what happens if these people disagree in terms of their assessment of how much control the individual is indeed exerting over his or her continued drug use?

Also the inclusion of “health and wellbeing and participation in the rights, roles and responsibilities of society”:

These are grand terms, but what exactly do they mean? Do they mean that drug treatment services need to be enabling drug users to become good parents, to find work, to be housed, to vote, to understand current political issues, to be happier in themselves, to have better relationships with their families and friends, to not commit crime, to be greener in their lifestyle?

The list is potentially endless of the things that drug treatment services could see themselves doing which are all cumulatively about maximising an individual’s sense of health and wellbeing. But how well placed are drug treatment services to take on these additional challenges when they have found it so difficult to take on the challenge of enabling individuals to recover from their drug dependence?

I might have worded it differently, but this emphasis on recovery as something that is holistic is important. Addiction tends to infiltrate every aspect of the addict’s life and it is not always self-correcting once abstinence is achieved. Good treatment and recovery support services must be prepared to address employment, family life, physical health, mental health, community involvement, etc. It is overwhelming, and we don’t have to do it all ourselves (Much of it can be achieved through coordination of services–not just passive referrals.) , but the alternative is a system that fails and loses the confidence of addicts, their families, other professional helpers, and the public.When this confidence is lost, the stage is set for criminalization or a system that relies on methadone.

7 thoughts on “Treatment reform in the U.K.

  1. Keep in mind, though, that the USA has long had the very system you desire–abstinence based, 12 step theology in 97% of all treatment centers, with heavy emphasis on counseling, meetings, job training, physical health, etc. Even so, the relapse rate for all addicts–but for opiate addicts in particular–is huge. It is just not very successful. That is why MMT was developed in the first place.It is just as wrong to put all the country’s reliance on MMT as it is to put it all on abstinence based treatment. Drug addiction is notoriously difficult to treat, and the results of untreated addiction are very serious indeed, for the patient and for society. We need to open our arms to any and all methods available to have the widest range of choices for the afflicted–one size does not fit all.

  2. “the USA has long had the very system you desire”Nothing could be further from the truth. The American treatment system is a disaster right now. It was decimated in the 1990s. It could be argued that this destruction was well-earned with excesses in diagnosis, cookie cutter treatment, wild success rate claims, etc. What we have right now is a system where most of the people who get treatment get inadequate treatment. In the public system, our detox sees homeless people referred to once a week outpatient treatment every day. That and MMT are the only forms of treatment that are available on demand. For people with private insurance, they get pretty much the same but might get a few days in a medical detox stay the beginning. The other option is out-of-pocket. For these people, we have an explosion of residential treatment programs that are exploiting this void and profiteering from people with deep pockets and scared families who are mortgaging their homes tp pay for treatment. Clients pay more than $20,000 per month for one or two months and then are back into the wilderness.I don’t know where you’re from or where you’re getting this 97% number from. Around here, MMT is available on demand, and it has been for the last 14 years that I’ve been working in the field. There are definitely a lot of 12 step oriented programs, but nowhere near 97%. I’d say about 50% of the programs in our area could be considered 12 step oriented, and all of the outpatient programs would happily work with a patient who wanted to use alternatives to 12 step programs.The system I desire would resemble what we do for impaired physicians. High intensity, high quality treatment initially, followed by long term lower intensity treatment, relatively instense case management, and high intensity monitoring that tapers over a period of 3 to 5 years. If there are an relapses, services are temporarily intensified and re-evaluated. Their model resembles a chronic disease management approach.Philadelphia is trying to do something along these lines with their public system. Finally, addiction is difficult to treat and doesn’t always respond well, but that could be said of a lot of diseases that we invest heavily in treating. Treatment does work when it’s provided an adequate dose, for an adequate duration. There are a lot of bad programs out there, but there are also a lot of programs that never have a realistic chance to help someone because of funding constraints. We’ve found creative ways to deal with these limitations, primarily non-clinical recovery support services. I won’t pretend to be something I’m not. I’m recovering and maintain my recovery in a 12 step program (I’m also agnostic.), and I work for a treatment program that is 12 step oriented. But I do not think that my recovery path is the only way to recover and I don’t want the treatment continuum to be a bunch of clones of my program. You keep making these straw man arguments, “the very system you desire–abstinence based, 12 step theology in 97% of all treatment centers” and “one size does not fit all”. Who says that this is the system that exists, the system I want, or that I believe one size fits all? Not me.

  3. One more thing. Though the agency I work for is 12 step oriented, we do, particularly in our outpatient program, work with people who want to use other paths to recovery. In outpatient we also work with people who don’t want to pursue abstinence. Again, I don’t want a system the shoves everyone into 12 step oriented programs, even open minded ones, but keep in mind that 12 step does not equal closed minded and militant.

  4. Well, Jason, here is an example.I had a twenty year history of opiate addiction. I was sent to 13 seperate rehabs–inpatient, outpatient, therapeutic communities, Drug Court–every variety you can imagine, and quite literally every treatment program my large American city had to offer. Every last one of them offered the 12 steps, and ONLY the 12 steps, as a treatment option. I was told at every one of them that if I did not embrace the 12 steps fully, I had no hope of recovery at all. So, I did–I did exactly as I was told. Nevertheless, I relapsed every single time. And not once did anyone ever refer me to methadone treatment, though my addiction was solely to opiates and there were 3 clinics in my town. I was simply sent back to the exact same type of treatment I had already failed countless times.There are people who do recover with 12 step based theology and I applaud them. Nevertheless, this is NOT sceince based, evidence based treatment–it is a support group that has been turned into a “treatment modality” with little or no evidence to back it up. http://www.soberforever.net/“45% of the people who attend Alcoholics Anonymous meetings never return after their first meeting95% never return after the first year.Based on Alcoholics Anonymous World Services’ own statistics Alcoholics Anonymous has only a 5% retention rate. Those who leave AA look elsewhere, such as conventional alcohol rehabs and drug treatment for solutions, but 97% ofconventional drug rehabs and alcohol treatment centers are 12 step or AA based, thus individuals essentially rejoin AA.”In an internet search for treatment centers that were specifically NOT 12 step based, I was able to find only a couple of places. As a patient advocate I have written to many centers asking if a patient who did not subscribe to 12 step theology would be welcomed there and in every instance they either ignored me or wrote back to say that such a patient could not succeed at their program and should find another one. http://www.orange-papers.org/orange-effectiveness.htmlI disagree with your ideas about treatment as it is offered here in the states. I most usually did not have money or insurance to pay for treatment–in fact, only 3 times out of the 13. Even so, I was given lengthy inpatient stays as recently as 2001–stays of up to 10 months in length. There are quite a few rehabs here in my town that offer inpatient treatment options for those who cannot pay at all, or who cannot pay very much. We also have a methadone clinic that offers subsidized slots, and two that are private pay.Even methadone clinics often compel their patients to attend twelve step recovery groups. because many of their counselors come from a 12 step background, even though the 12 steps are diametrically opposed to methadone treatment:http://www.na.org/bulletins/bull29.htmJason, it does surprise me that anyone in the industry could disagree with the fact that the vast majority of treatment centers in the US subscribe to the 12 step model. I am not saying that other things are not incorporated, such as cognitive therapy, etc, but acceptance of the 12 step modality is essential to these programs and patients who resist them are usually not considered successfully treated.I was trained as a substance abuse counselor a few years ago. During our training, we had a speaker from the staff of a local MMT clinic. Our teacher asked us to keep an open mind–that we owed it to our future patients to tell them about ALL their available options without personal prejudice. Nevertheless, after the presentation, the class members all stated that they would never refer their patients to anything but 12 step based treatment because they “knew” that this was the only effective method of treatment–their sponsors had told them so and they believed it. This is the prevailing attitude, and if only someone had steered me in another direction a bit earlier in my addiction I might have been spared a lot of loss and destruction.I am merely stating that the UK seems to gravitate primarily towards MMT and the USA primarily towards 12 step based abstinence treatment, and that neither method is exclusively successful nor should they be offered in exclusion to other methods–that’s all.

  5. You’re being specious now.1) There is ample evidence that 12 step facilitation is ONE evidence based approach. Further, I’m not aware of ANY programs that are purely TSF.2) You keep bringing up this 97% number without a source. A quick search on the SAMHSA treatment locator finds that 15% of the licensed programs in my county are methadone. You haven’t offered any info about your region, so I can’t do a search of your region.3) You previously defined twelve step oriented this way: “97% of the treatment centers in the USA use the 12 step model exclusively. For example, a typical center might hand the incoming patient a copy of the Big Book and tell them to keep it by their side and read it every day and that they will be quizzed on their knowledge of the steps. (often you must memorize them). Then, the patient goes to various groups, most of which have a 12 step theme (i.e., step 1, making amends, getting a sponsor, etc). Usually, 12 step members will come in each evening to “bring a meeting”, or the staff will take patients out to attend an area 12 step meeting. And usually patients must get a sponsor and work steps 1-5 before they can be discharged. The entire center is usually saturated with 12 step material, 12 step literature, 12 step banners and signs, 12 step lingo, and 12 step based counselors who believe it is the ONLY way to recover.”Very few of the programs in the treatment locator would fit that description. Many make a lot of 12 step referrals and integrate elements of TSF, but don’t force, or even push it on anyone. Several don’t integrated TSF at all. 4) You completely lost me when you cited the Orange Papers as a source. This paper rebuts the 5% success rate claim (as well as the 93% claims from the “good old days”). http://hindsfoot.org/recout01.pdf 5) Regarding the state of the system: * Private SA spending per covered life fell by 73.6 percent in nominal dollars from 1992-2001.  (Mark & Coffey, 2004. Health Affairs 23:6)* Substance abuse spending per covered life (in constant dollars) dropped from about $21.16 in 1992 to about $4.46 in 2002.   (Mark & Coffey, 2004)* Inpatient lengths of stay plummeted from often being 28 days in 1988 to 7.7 days in 1998. (NAPHS)* A growing trend toward outpatient treatment; In 1992, 73 percent of spending was in inpatient settings, while in 2001 this figure was only 44 percent. (Mark & Coffey, 2004)* The number of methadone providers grew by more than 47% from 1993 to 2005. (TIP 43) * The number of Veterans Administration residential and inpatient treatment beds dropped by 34% between 1994 and 1997. (Humphreys, 1999)6) You didn’t merely suggest that there the U.S. is overdependent on TSF. I’ve got mixed feelings about that statement, but I wouldn’t argue with it. You made characterizations about the “treatment system [I] desire” and engage in quantitative and qualitative hyperbole about the role of 12 step programs in the American treatment system. There’s a lot wrong with the American treatment system and the experience you describe is ONE of the things that’s wrong with it. I’d consider myself a potential ally for someone like you. I recognize that my path to recovery is not the only path and I want more diversity of services in the American treatment system. These argument tactics only alienate potential allies.

  6. I do not believe that Methadone is a viable solution for any sort of addiction. The kick from methadone can be many times worse than heroin. The real solution to long term recovery is handling of the issues that precipitated, perpetuated, and then prolonged addiction and addictive behaviors. “Guide to Addiction Recovery for a Lifetime” is a great little book I found on the net and is free for the asking at http://www.stopaddiction.com Though not all may agree with a drug free approach it (the booklet) is a good starting point

  7. The definition of recovery as posited by the official sounding, but wholly self appointed United Kingdom Drug Policy Commission,(UKDPC) is no more than a desperate attempt on their part to sideline the concept of treatment which leads to drug free recovery. Indeed judging from this and previous comments from this organisation, it appears that their main agenda is to triviialise the devastation caused by the use of addictive drugs of destruction, as a stepping stone to legalisation. Given that their ostensible reasons for seeking the latter fail to stand up to critical examination,one can only speculate as to their real reasons.Among their other pronouncements the UKDPC constantly exhort us to ‘look at the evidence’. I would therefore suggest that if they had followed their own advice in this instance they would have acknowledged that for those who are addicted/dependent on psycho active substances have, among other things, lost their ability to control, either or both, the quantity and frequency of use. (DSM-1V and ICD-10) Their suggestion that such people are capable of ‘sustained control’ is not only a blatant disregard for scientific evidence, it is indicative of the lengths they are willing to go to in pursuit of their ideological and possibly more obscure reasons for their attempts to dismiss abstinence focused recovery as a viable option.They compound this arrogant disregard of the evidence by their ignoring the further scientific evidence which has emerged over the past 15 years which clearly shows that the ongoing use of addictive drugs, by those who unfortunately have developed addiction, destroys various parts of the brain and its interacting systems, to the point that the ability of the user to make a free choice of continuing to use or not has been eroded. Psychiatric news July 6 2007)If the views of the UKDPC are purely ideological, they are misguided. Indeed one is reminded of the views of Freud when he published two papers wherein he claimed that cocaine was a ‘cure’ for alcoholism and morphine addiction.The continuing insistence on long term use of methadone, in itself a highly addictive drug, defies the object of treatment which should of course intitially be the alleviating of the symptoms, followed wherever possible by recovery. Since methadone is addictive and has horrendous side effects including, but not limited to, mood swings, hallicinations, together with feelings of unease, restlessnes, agitation and being unwell, it an oxymoron for the UKDPC to suggest, or even imply that those engaged in the long term use of this substance can ever enjoy what they describe as ‘health and wellbeing’.One also needs to recognise that many of the pharmaceutical products to treat the foregoing problems are contraindicated with methadone, as indeed is alcohol, and other hypnotic sedatives.The other inconvenient truths that the UKDPC failed to mention are (A) the diversionary abuse of methadone which is so common in the UK, and (B)the established evidence that the vast majority of those on methadone continue to misuse othe addictive substances.Methadone, in common with the plethora of drugs which are now emerging to treat opiate addiction, is beneficial from a short term point of view in assisting heroin addicts, who wish to quit, through the early stages of withdrawel. Administered in gradual reducing doses, and accompanied by a combination of psycho social treatment and attendance at 12 step fellowships it has a valid place in the cycle of recovery. However in the abstinence of those provisos. it is opening the door to developing further addiction. As such it cannot be regarded as harm reduction. The best one can hope for is that Injecting Drug Users who have not acquired HIV, aids and other blood born diseases are prevented from doing so. At the time of writing, given the increase in HIV and Hepatitis C in the UK (health protection agency) the current treatment protocols are failing to do even that.The claim that methadone saves lives is only partially true when one takes into consideration the fact that whilst there has been an overall reduction in drug misuse deaths between 1999 nand 2004, we cannot ignore the fact that there was an increase in deaths between 200/4, largely due to deaths involving heroin/methadone and morphine. The sadest part of that fact is that the mortality rates were highest in young adults. Nor the inescapable truth that it was an increase in the mortality rates in this vulnerable group, which was the cause of the rising mortality rates during the 1990s.(Office of National Statistics)In view of the foregoing this writer suggests that the UKDPCs views on recovery are not only illogical and inexplicable, but show a complete disregard of both scientific and factual evidence. So the question is what is their real reason for doing so?

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