Over the past year, a dozen rehabs in the United Kingdom (U.K.) have closed and others have downsized or made counselors redundant. Unlike the United States, most depend on the state for client referrals — but the state referred only 3.6 percent of patients to abstinence-based treatment last year, creating a paradox of empty beds and waiting lists of people desperate to fill them. Taxes are spent supporting a redefinition of “recovery” which marginalizes and excludes drug/alcohol-free lifestyles or recovery as we know it. What is going on? I am putting my head on the block by speaking up.

Unlike the United States, few people in the U.K. can get into appropriate addiction treatment through their insurers; self-pay accounts for only about 8 percent of clients. Most must rely instead on the National Health Service (NHS), which is usually free. Drug policy is overseen by a special NHS body, the National Treatment Agency (NTA) for Substance Abuse. Treatment is implemented by 149 Drug Action Teams (DAT), answerable to the NTA.

Before the NTA was formed in 1977, Addiction Today reported treatment organizations’ concerns that the DATs were untrained and had no incentive — or sanctions — to effectively implement a national drugs strategy. Sadly, like many other forecasts, this has turned out to be the case, with only a few praiseworthy exceptions. It has been widely reported that, of the 128,000 people passing through DAT hands last year, only 3.6 percent were referred to abstinence-based treatment, no matter how clinically appropriate; and 3 percent of the total became drug-free.

This year, it looks as if only 2 percent of 195,000 patients will get this chance to turn their lives around. This has led to under-capacity in treatment centers, which cannot plan long-term for staff training, resources or financial overheads. It is not only a question of keeping people on methadone maintenance (MM) year after year, treating people as statistical units to meet political targets, but also of bad practice in prescribing. U.S. research showing MM with good outcomes is cited in psychosocial settings with a goal of abstinence. Evidence, to be published in Addiction Research & Theory, shows that MM clients in the U.K. receive an average of only four hours of meaningful psychosocial intervention across a full year. This is not sufficient to elicit meaningful life change.

Not only does “standalone” MM demotivate clients from the drug-free goals they presented with, but new research seems to indicate that, the longer a client is on methadone, the greater the damage to cognitive decision making. The NTA and other government officials say that there is no evidence that rehab works, and refuse to cite the strong and growing body of research indicating that treatment does actually work. Rather, the government contends that rehabs do not comply with mandatory National Drug Treatment Monitoring System needs. I emailed relevant treatment centers and within 24 hours over 50 percent responded that they do — but their outcome results are not being published.

So, how can these actual outcomes be presented to show that targets have been met and to ensure survival of new empires?

The figures rely on the Treatment Outcome Profile (TOP), a “validating” paper, which independent researchers describe as measuring only consistency of self-report, not validity. In general, clients tend to under-report criminal activity because of the stigma and fear of consequences.

So, if we know that clients will under-report drug use and criminal offenses at the structured interview, and if the definition of “recovery” excludes the 12 Steps or sobriety, then it is likely that between workers not asking the questions and clients not reporting stigmatized behaviors, there will be high levels of “reported recovery.” Thus, targets will appear to have been met.

Redefining recovery

For well over half a century, people recovering from addiction/ dependency on alcohol and drugs have used that term “recovering” or “in recovery” in the same sense that it was used and written by the founders of Alcoholics Anonymous (AA) in the 1930s and onward. So, where does “medication-assisted recovery” come into play? After all, the founders of AA worked were so forward thinking that they advocated psychotherapeutic interventions when they were in their infancy, and also sought pharmaceutical help. In the latter they were unsuccessful (LSD was not a good idea!) but science has progressed.
Should a definition of “recovery” encompass medication-assisted recovery, or should we differentiate with two definitions: “abstinent recovery” and “medication-assisted recovery?”

There needs to be a clear definition that would work not only for treatment centers, but also for state services, physicians and psychiatrists. Consider the following:

• What is an acceptable definition to reassure employers wondering whether to recruit or retain an employee “in recovery?”
• What is an acceptable definition for the company insuring the health of someone “in recovery?”
• What would persuade a college to take back a student “in recovery?”
• If today’s search for outcome statistics is to lead to clinical effectiveness and clinical cost-effectiveness, what definition will help us to measure outcomes, for both comparative purposes and for feedback toward program improvements?

A one-line statement cannot hope to encompass all that is involved in “recovering” from substance abuse or dependence.

With that, let’s examine some of the definitions currently in play:

“Recovery from substance dependence is a voluntarily maintained lifestyle characterized by sobriety, personal health, and citizenship,” stated the Betty Ford Institute Consensus Panel, in the Journal of Substance Abuse Treatment last year. However, we must search through seven pages of explanations to find, under the heading, “Sobriety sustained by medications,” that: “those who are abstinent from alcohol, all illicit drugs, and all nonprescribed or misprescribed medications would qualify for this component of the definition regardless of whether those behaviors were maintained by a medication, a form of unforced outpatient treatment, support from a recovering peer group, or some alternative lifestyle.”

This definition is an expansion to include medication as engagement, but obviously does not exclude abstinence, regarded by most as a vital base for change to occur.

“Recovery is a process through which an individual is enabled to move-on from their problem drug use towards a drug-free life and become an active and contributing member of society,” declares this year’s Scottish drug policy document, The Road To Recovery. Although accompanied by 95 pages of policy, the definition has the virtue of being able to stand alone.

“This commitment to recovery, to responding to the desire of people who use drugs to become drug free, lies at the heart of this strategy ...  Aiming for recovery means coupling common sense with aspiration, pragmatism with idealism ... public money invested in drug treatment services should have clear outcomes attached,” Scottish member of parliament Fergus Ewing writes in the Ministerial Foreword (www.scotland.gov.uk/Publications/2008/05/22161610/0).

The Scottish policy agrees with a United Nations report that states: “harm reduction is often made an unnecessarily controversial issue, as if there were a contradiction between treatment and prevention on one hand, and reducing adverse health and social consequences of drug use on the other. This is a false dichotomy. They are complementary.”
I repeat my endorsement of this and, sadly, have witnessed actions by a few organizations this year to reignite the old harm-reduction versus abstinence debate instead of truly collaborating.

Organizations in the U.K. have started to understand one another’s work and inter-refer clients across a true spectrum of care. Professionals working in alcohol- and drug-free services are more willing than ever to collaborate with other philosophies for the benefit of those who need help.

The newly-created, self-styled U.K. Drug Policy Commission (UKDPC) — not officially a government body, but receiving charitable funding of more than $2 million over three years and with an NTA director on its board — has come up with the following definition, which omits mention of “sobriety” or “drug-free life.” “The process of recovery from problematic substance use is characterized by voluntarily sustained control over substance use which maximises health and wellbeing and participation in the rights, roles and responsibilities of society.” This is slightly altered from its earlier version, which also focused on “control over substance use.”

As the first redefinition to publicize itself in the U.K., Addiction Today sought comment from CEOs/directors in the treatment field; about half of them replied (30 organizations). Of these, only 30 percent thought the UKDPC definition covered substance abuse; only 25 percent thought it covered substance dependence; and only 15 percent thought it covered co-occurring disorders. Notably, 70 percent thought it should cover all three. The survey results can be found at: www.addictiontoday.org/addictiontoday/2008/06/ukdpc-non-conse.html

As a courtesy, I delayed publication of this until after attending a UKDPC meeting to which I had been invited; I had believed it wanted a consensus and would respond to the views. However, although only three people agreed with the use of “control” and 11 others who were present at the meeting disagreed with the definition, the majority view was ignored. I issued a statement that neither my name nor that of the Addiction Recovery Foundation be associated with the definition project due to nonconsensus. I published this statement with the survey results: “The UK Drug Policy Commission charity was funded to draw up a consensus definition of ‘recovery.’ Addiction Today sees the definition publicly rolled out in May as divisive to the field, excluding those who seek alcohol- and drug-free lives for themselves and/or their clients.”

My statement elicited a range of reactions, including UKDPC Commissioner Professor John Strang publicly attacking “abstentionists” and then enlarging my statement to fill the stage backdrop of the Mermaid Theatre at the NTA’s annual conference in June. Professor Strang then proceeded to speculate on the motives of the Addiction Recovery Foundation. “It is not proper for them to disseminate these views,” he told the 450-strong audience. “I am a harm reductionist.” To be fair, this charity has received correspondence from the UKDPC with the opposite view, too.

Not only did the NTA give Strang an hour, but the entire afternoon of its annual conference was dedicated to its definition of recovery. My taxes were used by the NTA to publish a 16-page pamphlet, of which seven of those pages were devoted to the UKDPC definition. Professionals who had argued at the conference against the definition — including Tim Leighton, who heads the Centre for Addiction Treatment Studies — were portrayed in photographs with quotes which conveyed an altogether different impression.

The reason soon became clear. “It was our intention from the start to link to TOP,” stated UKDPC CEO Roger Howard. And thus, outcome measures are blurred, to help political statistics.

Independent analysts of drug policy are also disquieted that an important debate about treatment choice and outcomes could be lost in the ‘consensus’ process. What is at issue for them is that the concept and practice of “maintained control over substance use” could “act as a barrier to the more liberating recovery that is not reliant on the prescription pad.”

“By characterizing recovery as voluntary maintained control over drug use, the UKDPC combines in one definition those whose drug use has ceased and those who continue to use drugs in a ‘controlled’ way. This is flawed definition on a number of fronts,” wrote Neil McKeganey, Professor of Drug Misuse Research at the University of Glasgow. “For example, it is hard to see how addictions services can operationalize this notion, since one person’s control is likely to be evidence of another person’s denial. It is also hard to see how a definition of recovery that encompasses continuing drug use will enable addiction services to answer criticism of why so many people leave treatment with their drug dependency intact. The UKDPC thus risks portraying recovery as a journey without end.”

The Prisons and Addiction Forum at the influential Centre for Policy Studies, cofounded by Margaret Thatcher, endorses this: “This definition effectively excludes 12-step and similar approaches to recovery — the very thinking that re-introduced the need for abstinence-based recovery,” wrote chair Kathy Gyngell. She is also author of the Addictions section of the acclaimed Breakthrough Britain report.

Where does that leave us?  Well ... awaiting your definitions. Watch this space as we seek true consensus.

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Kristal  - Methadone saved me life   |173.190.27.xxx |2010-12-15 00:00:55 Well, despite what you say Rehab did NOT work for me. I was going through life a debilitated heroin and pill addicted phene stealing and doing many other horrible things at age 15 (I actually started heroin at age 17, but have never shot up in my entire life). I had three pending criminal charges on my record at the time of entering treatment and was taking over 200 mgs of Oxycontin daily along with heroin on occassion and that was after going to Rehab several times. Once I entered MMT over 4 years ago my life changed for the better. If I had someone like you telling me that Methadone wasn't going to work and what not I probably would have remained addicted and sick for the rest of my life, but luckily I did what I felt was right against everybody's wishes for my recovery. Now, they are thanking the Lord above that I got help when I did. Rehab may work for some, but for many it DOES NOT, especially once they have ruined the Reply 0   0

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