The Advisory Council for the Misuse of Drugs. the government’s official advisers, just (23 October 2015) published the second instalment of their report on treatment for heroin users.
The first part of the report was published in November 2014 and found that imposing a time limit on treatment would result in the majority of addicts relapsing into heroin use with serious unintended consequences, including increased drug driven crime; heroin overdose; deaths and the spread of some blood borne viruses.
This part, formally entitled:
How can opioid substitution therapy (and drug treatment and recovery systems) be optimised to maximise recovery outcomes for service users?
is very critical of the current state of drug treatment/recovery.
The report comes to the following main conclusions:
1: Outcomes are difficult to achieve but all can achieve some
Overcoming heroin dependence is difficult; optimism is important but within realistic expectations. Some people will become free of dependency, while others will need ongoing medication; the ACMD says its important not to discriminate against this latter group because this will limit the recovery outcomes they can achieve.
2: High quality opioid substitution therapy is cost-effective
The ACMD uses strong language in its defence of treatment: “There is strong evidence that high quality drug treatment for heroin users is cost-effective and the impact of locally commissioned services are as, or more, important to service user outcomes as the service users themselves.”
3: Local recovery-orientated drug treatment systems are required
The ACMD regarded this issue as requiring more exploration because local systems differed significantly; the report lists four different common”cultures”:
- some systems appear to be ‘risk averse to attempting abstinence’ for fear of relapse and harm to service users;
- others operate ‘slow reductions’ which risk being poor quality, low dose opioid substitution therapy;
- some encourage abstinence attempts once a service user has built sufficient assets; and,
- others may encourage abstinence attempts ‘too early’ resulting in relapse.
4: Does the system have low expectations of heroin users in OST?
ACMD heard evidence that ‘hope and optimism’ for recovery outcomes has improved and at least three-quarters of services users surveyed reported service expectations of recovery and abstinence. However, this appears to be variable among staff and services and complicated by different ideas about ‘what works’ or what is ‘best for service users’.
5: How good is opioid substitution therapy?
The ACMD is extremely critical of current provision. It expresses serious concerns about whether service users get enough of a ‘therapeutic dose’ of quality clinical and psycho-social interventions, particularly in the context of shrinking local resources.
There is concern that some services do not appear to be providing adequate doses of opioid substitution medication, or enough monitoring of ‘use on top’ (see 6 below) by drug tests, or enough use of supervised consumption.
The ACMD was very concerned that the interventions with the strongest evidence-base: contingency management, behavioural couples’ therapy and family therapy do not appear to have been widely implemented.
Access to mutual aid (peer support) appears to be more widespread and growing, but there was mixed evidence on how much different treatment providers facilitated the development of mutual aid services and encouraged service users to make use of them.
6: Use on top
Research has consistently shown than many heroin users getting methadone or other substitute medications continue to use heroin “on top”, particularly when they first get a prescription. Those who stop using heroin within six months of starting treatment are much more likely to have positive outcomes. There are national guidelines in place to try to minimise continuing use of heroin. The guidelines recommend regular random drug testing; but the ACMD was concerned to hear that the use of drug testing is becoming less frequent due to cuts in resources.
7: Difficulties in accessing other services
Dependent drug users normally have a host of problems and require a co-ordinated response from a range of services. The ACMD is particularly concerned that access to treatment for both mental health problems and hepatitis C appears to be variable. This is of great concern as ongoing physical and mental health problems are obviously a barrier to achieving recovery outcomes. The ACMD would also like to see more resources invested into helping recovering drug users find work and says that tackling stigma among employers is a key issue.
8: Why is drug treatment so variable?
One of the key reasons highlighted by the ACMD is the constant re-commissioning of local services, which together with cuts in resources, appears to be damaging many treatment systems.
The ACMD found that the current quality of drug treatment in England varies significantly and is being compromised by frequent re-procurement and shrinking resources.
The report calls for investment in drug treatment to be protected and a national quality improvement programme to be implemented. It also recommends that ‘churn’ in local systems should be reduced and that more should be done to stop discrimination against people in recovery from heroin addiction.
Annette Dale-Perera, co-chair of the ACMD’s Recovery Committee, said:
Government has done well to achieve widespread recovery-orientated drug treatment for heroin users. Treatment protects against drug related death, ill health, chaos caused by addiction, and crime and can help people turn their lives around. We need to act to improve and not lose this valuable asset to society.