There’s a narrative that’s been around for a while, but it’s been gaining ground in the last few months. This last couple of months alone, it’s been in the ether, permeating social media conversations and even appeared in an academic paper. The issue relates to recovery-oriented drug policies and the tone is negative.
The thrust of this narrative? It’s that recovery-oriented drugs policies cause excess deaths. In the latest iteration I read that Scotland’s previous drug strategy (The Road to Recovery – which I’m going to call R2R) is to blame, or in less certain pronouncements, ‘may be to blame’ for Scotland’s high drug-related deaths. When you look for the evidence to back up such claims, it is hard, if not impossible, to find. So, are these claims fact or fiction?
In the 1980s the swing away from an abstinence aim of drug and alcohol treatment to harm reduction was largely driven by the developing harms associated with HIV. This was a welcome and necessary development, but by the early 2000s, it was beginning to seem to some that treatment options were limited and that we may have set the bar too low. When R2R was introduced, a readjustment took place. Did that readjustment cause harm?
In a recent paper, which I recommend you read, the focus is on benzodiazepines but there is a reference to drug policy more generally,. Colleagues write about changing drug markets in light of reductions in benzodiazepine prescribing:
“This may have been further exacerbated by a national drugs policy in 2008 based on achieving abstinence from all drugs. By discouraging agonist treatment a potential unintended consequence was that people who use drugs looked for supplements to diminishing prescriptions doses of methadone and buprenorphine.”
This paragraph has only one reference (to the R2R drugs strategy) but contains some significant statements which are presented as ‘potential’ facts. What are they?
- The national strategy was based on achieving abstinence from all drugs
- Agonist treatment was discouraged
- Prescriptions were reduced
- As a result, other substances were sought
It’s important to point out that my colleagues’ paper focuses on possible negative consequences from a reduction in benzodiazepine prescriptions ( R2R is not under the spotlight) so I’m picking up what appears to be a minor aside, but the underlying principle is one that deserves scrutiny. Is a recovery focus a dangerous focus?
Abstinence from all drugs?
The Road to Recovery was published in 2008. Drug-related deaths were on a gradually increasing trajectory before then. From the year of publication of R2R to 2010, drug related deaths actually declined before climbing gradually from 2010 to 2013 when they really took off, so it’s quite hard to link the policy directly to increasing drug deaths.
In any case, is it true that was R2R an abstinence-focussed policy? How many times, for instance, is abstinence mentioned in the text of its 96 pages? I’ve counted. It’s four. What are they?
- The first time abstinence is addressed in R2R is a historical reference to the policy response in the 1980s to both HIV and crime which led to a necessary movement away from abstinence to Scotland’s harm reduction focus.
- The second time (ironically) is to decry the artificial harm reduction vs abstinence divide and to point out the complimentary nature of these approaches.
- The third time is when it mentions the programme I work in, which was used (amongst others) as an example of how services can be broadened to offer choice – not instead of, but as well as.
- The fourth time is when it is pointed out that some achieve their recovery through abstinence and others through treatments which aim at stabilisation or reduction in use: hardly an abstinence-only ordinance.
So what is recovery?
Recovery in this strategy embraces reducing harm, reducing use, stabilisation, MAT and, yes, access to treatments associated with abstinence. At no point does the strategy call for reductions in access to OST – indeed it highlights and quotes papers underlining the primacy of this approach, calling for improved delivery of methadone (p22) and emphasising the role of GPs and pharmacists in providing substitute prescribing (p28-29). The Scottish Government ‘strongly’ supported the Orange Book Guidelines as ‘an authoritative guide’. The Orange Book promotes MAT as an evidence-based approach.
In R2R, recovery is not defined in terms of abstinence, but in terms of achieving personal goals, preventing relapse to illicit drugs, improving relationships, engaging in meaningful activities, building self-esteem, and building a home with family – the things patients consistently tell me (and I’m guessing, many other practitioners) that they want from treatment. When we conflate ‘recovery’ with ‘abstinence’ we get into this kind of muddle.
Harm reduction is often made an unnecessarily controversial issue, as if there were a contradiction between treatment and prevention on the one hand, and reducing the adverse health and social consequences of drug use on the other. This is a false dichotomy. They are complementaryUnited Nations 2008
It’s not that controversial
What’s in the R2R in terms of its focus on recovery is not new or even without consensus. The Reducing Harm, Promoting Recovery report of 2007, the Essential Care report of 2008 and the subsequent Independent Expert Review on Opioid Replacement Therapies in Scotland, commissioned by the then Chief Medical Officer, Sir Harry Burns, have similar themes and recommendations. They all agree on the prime importance of opioid substitution but point out that recovery is much more than a prescription and that Recovery Oriented Systems of Care (ROSC) are needed to help people achieve their goals. The current National Mission to reduce drug deaths is similarly broad and ambitious.
What the R2R strategy did was raise the bar beyond a prescription, explore goals and introduce the notion of individual choice. A bit like our current strategy. People deserve to be able to make informed choices. They deserve access to a range of evidence-based treatments.
Despite its benefits in reducing harms, some people do not want OST to be a forever thing. Some have moved on from OST and are in long term stable abstinent recovery. Every major review and policy paper that informed the R2R (and the current alcohol and drug strategy in Scotland) has extolled the benefits of OST but has also highlighted what is missing in our services.
It is not a criticism of OST to highlight areas where we need to do better. For instance, although OST is the fundamental treatment approach for those with opioid use disorders, if we think in terms of recovery/flourishing we actually don’t know much about whether it helps people achieve their life goals.
In R2R, nowhere is abstinence promoted over MAT – this idea is nowhere to be found in the referenced reports and reviews. Dr Brian Kidd the Chair of the Independent Expert Review despaired over the lack of ‘institutional memory’ in our structures and policies that have failed to see us take on board the lesson that MAT, while essential, is not the whole answer and that choice, opportunity, governance, data/evaluation, ROSCs, detox and rehab also need to be present.
Agonist (OST) treatment discouraged?
At the time of R2R I was working in an integrated system which encompassed harm reduction, MAT, detox, and abstinence. My colleagues working in specialist addiction services in the community absolutely did not discourage agonist treatment (opiate substitution); very much the opposite – it was and still is the primary focus of treatment for those with opioid use disorders.
I was teaching on the RCGP Certificate in the Management of Drug Misuse Part 2 course during this period. The course focussed on the evidence-base for OST and taught primary care practitioners how to embrace harm reduction and OST principles. The R2R was discussed, but we did not see it as a policy that promoted abstinence over OST. Yes, we also covered the concept of recovery, but not instead of OST. If prescriptions for OST were reduced as a direct result of R2R, I’d be interested to see that evidence;. Indeed, we were strongly encouraging GPs to prescribe.
Recovery is about helping an individual achieve their full potential – with the ultimate goal being what is important to the individual, rather than the means by which it is achieved.
Recovery policies and drug deaths
It is possible that by shifting the focus to person-centred outcomes, the R2R did impact negatively through local interpretations and practice, but unless there is evidence to back this up, this notion remains opinion. Similar claims were made during the work I was involved with when a committee of experts updated the UK ‘Orange Book’ National Clinical Guidelines on Drug Misuse and Dependence. On the 15th of September 2015 in London the working group heard evidence from Public Health England that they had studied the data on drug-related death data in England and explored whether these could be linked to ‘the recovery agenda’. They found no such link.
I don’t believe that the Road to Recovery was an abstinence-based strategy, nor that because of it, prescribers were under any pressure to reduce access to OST. I don’t think it’s accurate to describe the R2R as ‘based on achieving abstinence from all drugs’ (implying this includes MAT). I have not seen evidence that R2R contributed to our drug deaths crisis. What I have seen is a painful divide developing between harm reduction and recovery. When we repeat opinion and particularly when we package it as fact, this adds to the harm reduction good, abstinence bad narrative. This divide is turning into an ever deeper wound that needs healing, not poking.
The substance abuse field in both its research as well as treatment efforts is not giving due consideration to flourishing. We need to renew our efforts to give meaning and purpose to the lives of patients.Eric Strain
There are lots of people in long term abstinent recovery from opioid use disorder in Scotland. Many of them acknowledge the lifesaving impacts of harm reduction interventions and MAT. There are plenty of people in recovery on MAT who have resolved their problems and are very happy to remain on medication. They are in recovery too.
Recovery journeys tend not to be linear; people may move between treatments and a particular status. Their needs and goals should be central to policy, as should measures to reduce harm. Our policies need to reflect the need for a variety of options and emphasise how important the elusive Recovery Oriented Systems of Care are in ensuring joined up approaches.
We should celebrate the gains individuals make in terms of recovery whether that’s through MAT or abstinence. I don’t think the R2R was a perfect drugs policy – none are – but it did encourage us to think bigger. I don’t believe it is or was partly responsible for our catastrophic drug deaths, though if we keep saying it often enough, I suppose eventually we will come to believe it.
Continue the discussion on Twitter: @DocDavidM
Photo credit: https://www.istockphoto.com/portfolio/comicsans?mediatype=illustration (licensed)
 A McAuley, C Matheson, JR Robertson, From the clinic to the street: the changing role of benzodiazepines in the Scottish overdose epidemic, International Journal of Drug Policy, Volume 100, 2022