Reviewing the evidence on drug misuse treatment
Last week (26 January 2017), Public Health England published a new report: An evidence review of the outcomes that can be expected of drug misuse treatment in England.
The report begins with a brief summary of the current nature and prevalence of drug misuse, the history of drug treatment in England, and the outcomes it achieves. The international research literature on treatment effectiveness is then summarised, with comparisons made to effectiveness in England. The report uses modelling to consider the likely size, characteristics and needs of the drug treatment population in the next four years, and reflects on the challenges for local treatment systems and recommends how treatment outcomes might be measured, maintained and improved.
What can be expected of drug treatment?
Like most recent PHE documents to my mind, this review is written in a somewhat defensive, but bullish tone; putting the most positive spin on every finding. There is much to be proud of in the English treatment system but the continual insistence on choosing the most favourable comparisons in every aspect, paradoxically (for me at least) undermines this.
Now that I’ve got that off my chest, what does the review say?
How England drug treatment compares internationally
The PHE evidence shows that where comparisons were possible, the treatment system in England is performing well – with 60% of all opioid users in treatment – among the highest treatment penetration rate reported.
Other areas where treatment outcomes in England are comparable with or better than other countries and compare well to the scientific literature included:
- access to treatment (97% within three weeks) is comparable to other countries
- the rate of injecting among all 15-64 year olds (0.25%) is relatively low
- the rate of drop out from treatment before three and six months (18% and 34%) is comparable to the literature (28% on average)
- a very low rate of HIV infection among injecting drug users (1%), which compares favourably internationally
- the rate of Hep C infection (50%) is lower than several other countries with available data
While largely positive, there are two key areas of concern that need improvement:
- the rate of opiate abstinence after three and six months of treatment (46% and 48%) points to relatively poorer performance in comparison with the literature (56% on average)
- the drug-related death rate (34 per million in 2013) is substantially lower than the USA but considerably higher than elsewhere in Europe. The rate in England has now increased to 42 per million in 2015 (Wales and Scotland have also seen an increase over this period)
The changing treatment population – future challenges
The majority (around 75%) of people currently in drug treatment in England have problems with opiates, mainly heroin. In recent years we have seen an increase in the proportion in treatment with entrenched dependence and complex needs, experiencing cumulative physical and mental health conditions and we expect this is likely to continue to rise.
This changing population of older heroin users will present challenges for services and local councils. They are less likely to successfully complete treatment and more likely to die from long-term conditions and overdose. It is important that we help this particularly vulnerable group to access appropriate general healthcare services and other forms of support.
There are reports of increasing problems of misuse and dependence associated with some prescription and over-the-counter medicines. The use of new psychoactive substances (NPS) is also a threat, and is a particular problem in prisons.
New patterns of drug use and health risk behaviour are also becoming established including injecting NPS use, and drugs used alongside high-risk sexual behaviour (‘chemsex’). These require close monitoring and responses that range from managing prescribing practices to developing the skills of professionals.
Social factors are important influences
The evidence also shows that social factors are important influences on treatment effectiveness. Areas of relatively high social deprivation have a higher prevalence of opiate and crack cocaine use and larger numbers of people in treatment. Unemployment and housing problems have a marked negative impact on treatment outcomes and exacerbate the risk that someone will relapse after treatment.
Specialist treatment services are vital but treatment cannot do it alone and further support is needed to help people into lasting recovery through employment, decent accommodation and strong social networks.
The benefits of investing in treatment
Drug misuse has a significant cost to society as a whole, costing the UK an estimated £10.7 billion each year from health service costs, drug-related crime and economic costs such as premature deaths. Investing in drug treatment can impact on these costs and it is estimated that every £1 spent on treatment yields a £2.50 saving on the social costs of drug misuse.
The evidence is clear that treatment affords individuals and communities many benefits. Continued investment in treatment and in ensuring services are fully integrated with other healthcare and social services will save local communities money and help to address health inequality.
The PHE review “celebrates the benefits of investment in drug treatment and recovery in the positive outcomes we see in England“, but acknowledges two key challenges:
- are we doing enough to reduce drug related deaths, particularly amongst users outside the treatment system and how are we managing ‘use on top’?
- are we satisfied that the majority dying are not engaged and are the harm reduction and crime reduction benefits of treatment sufficient that ‘use on top’ is acceptable?
The one key issue I would have liked this review to address is the central one for any recovery-oriented system:
Why are our long-term recovery rates so low?
Apart from a recommendation to consider measuring longer-term (12 months) rates of treatment re-presentation, the review skirts this key question.