Comments

• 

  written on 22-Oct-2008

  egebamyesi says:

  Hello
  
  I believe the NTA don't want to get into a debate regarding real treatment as it might demand a little thought. They might even have to start thinking about the more complex issues of addiction, and as the nominated body tasked with steering thinking in this respect, are we expecting too much? I truly believe that understanding the world of residential treatment, and 'what works', is beyond them. Residential treatment providers i.e. those who are expert in changing lives, know the answer to most of the questions that need to be asked in this respect but i'll bet the NTA haven't even bothered asking.
  
  Shameful really.
  

• 

  written on 22-Oct-2008

  jonhibbs says:

  The point Paul Hayes actually made in Manchester was that all too often the debate around drug treatment sounded like “two people with their iPods turned up at full volume, shouting slogans at each other.” The NTA does not accept the polarisation of debate between abstinence and maintenance. It is a false argument, which encourages entrenched positions, and doesn’t help either the people working with drug users, or the users and their families themselves.
  
  The NTA believes in a balanced treatment system, in which a range of treatment options are available from which addicts can benefit at different points in their lives.
  
  That means methadone is available as the standard clinical treatment to start the process of getting heroin addicts off drugs. We make no apologies for that: the doctors at NICE recommend it. It means psychosocial interventions, so-called talking therapies, are available too, as well as detoxification, which may be offered in the community as much as in a residential setting, and a variety of other non-medical help and support. In addition it means abstinence-focussed treatment is suitable for some people, when they are ready to take advantage of it, and the clinicians judge it is likely to work.
  
  That is the NTA’s position. It often gets lost in the clamour of voices with different views, and in reporting by those with a vested interest in misrepresenting our view. You may have wished that Paul was positioned to defend methadone maintenance in Manchester – but what he said was that our aim is to get drug addicts into treatment in order that they come off drugs.
  
  Treatment is a means towards an end – and the end is overcoming addiction, getting drug-free, becoming abstinent. Some people are in treatment for a long time before they can get to that point, but that must not make us complacent. As Paul said in Manchester, all of us, policy-makers, commissioners and providers alike, should be ambitious for users.
  
  Jon Hibbs
  NTA
  

• 

  written on 22-Oct-2008

  McKeganey says:

  It is extraordinary that whenever one raises the evidence base showing the benifits of residential rehabilitation the predictable response from those defending community based methadone maintenance programmes is to point out that "no one treatment suits all". In fact of course with methadone occupying a near monopoly in the drug treatment world in the UK what we have is indeed "a one size fits all solution" with the vast majority of addicts in treatment being offered methadone. The NTA have called for a greater sense of aspiration on the part of those working in the drug treatment to do more than simply aim to stabilise individuals in the face of their continuing drug use. If that call is to be taken seriously the NTA have to be robust in defending the residential rehabilitation sector; they quite simply have to do more than offer belated guidance to commissioners. It should not have taken the BBC and under funded charities to draw attention to what is happening with our residential sector- that should have been something the NTA were aware of and addressing years ago. Sadly the NTA have been so focussed on numbers of drug users in treatment that they have all but ignored the residential sector.

• 

  written on 22-Oct-2008

  egebamyesi says:

  In response to the views of the NTA representative, do you really believe that the picture you paint is a true reflection of what's happening at practitioner level? Aspirations are driven by the belief that you might actually achieve what it is you are aiming for - for the majority of addicts I’m sure this is abstinence. Targets are borne of aspiration and I believe this is where the issue sits. Most of the key targets for the majority of providers are geared to measuring effectiveness up to the point of the individual accessing treatment – which in most areas is an option between Methadone and an uninspiring day programme. Speaking to these providers, you get a real sense that front-line resources are being shaped more and more to meeting this type of target, at the expense of the investments needed to develop and sustain robust therapeutic interventions. This imbalance will surely catch up with us and I envisage a scenario where thousands of addicts are sitting on scripts with nowhere to go but backwards. At the very least, could the NTA please view having large numbers of people in ‘treatment’ as an opportunity to treat them?

• 

  written on 22-Oct-2008

  McKeganey says:

  I think that part of the reason residential rehabilitation services have faired so poorly in terms of central government funding has to do in part with the emphasis on increasing the numbers of drug users accessing treatment. If your focus is on big numbers then you are in all probability likely to forget about the residential sector. However in addition I also think that the endangered position of the residential sector has also arisen as a result of a fundamental ambivalence towards abstinence that has characterised much thinking including government thinking over at least the last decade and a half. Those agencies emphasising abstinence have simply been out of step with much of that thinking that has emphasised instead the view that drug use for the most part is not harmful and indeed is socially acceptable. As a result of the proliferation of that view many abstinence oriented agencies have had to dilute the focus of their programmes so as not to offend the liberal view of drug use as socially acceptable. Increasingly however it is being recognised that the promise of harm reduction to enable drug users to continue to use drugs with minimal harm is being seen as deeply flawed- where individuals who have developed a drug problem continue to use illegal drugs there is almost an inevitability that they will continue to experience the problems associated with that use even where they are provided with the means to use the drugs they have sourced. In addition of course and wholly aside from the harms to the individual there is the persistence of harm to those in the drug users family and wider community. It is essential that we have drug treatment services that are focussed centrally not tangentially on enabling individuals to overcome their drug use. It is inevitable of course that not all individuals will be able to progress in their recovery at the same rate or do so with the same package of services. What is not acceptable though is the depressing "once an addict always an addict" view and the belief that recovery seen in terms of enabling individual's to lead a drug free life is the preserve of the view.

• 

  written on 22-Oct-2008

  tim1leg says:

  brilliant to see the debate moving along, this is brilliant Kathy, I have had one of those days when the B**tards could quite easily have got me down but thanks to you and a few other like minded folks, i am full of hope and wit again. Thanks all who have added comments too, cheered me right up.
  

• 

  written on 22-Oct-2008

  tim1leg says:

  I am reminded when i see quality like this that I am not alone!

• 

  written on 22-Oct-2008

  McKeganey says:

  Tim1leg the debate on our drug policies and drug treatment provision within the UK is important but it is not an easy debate to have in part because to criticise an orthodoxy of whatever kind carries a risk- in this case the risk that one might be ostracised by colleagues, that ones job may be made more difficult, that ones recovery may be impeded or whatever. In my own case I know that there have been occasions when our ability to bid for research contracts has been damaged by some of the things that I have said and written but throughout all of that it is important to say what one feels and believes to be the case. That is by no means easy and there is a certain vindictiveness in the drugs field that is indicative of the strength with which views and positions are adhered to. But the intentions of those who contribute to this debate are not to disparage or to wreck achievements but to try to ensure that we do better, achieve more, and help more people overcome the difficulties associated with their drug and alcohol use. Those are honorable not disreputable intentions and the debate needs to be encouraged not stifled.

• 

  written on 23-Oct-2008

  UKDPC says:

  While it may well be the case that the current availability, resourcing and uptake of residential rehab is insufficient, I think Kathy’s statement that “rehab is much better at getting addicts drug free” based on NTORS and DORIS studies is not quite the full picture and could be misinterpreted.
  
  These studies were designed to describe outcomes for the treatment system as a whole not to compare different treatment modalities, which would require randomised controlled trials or at least matching of the people entering the different treatment arms. Many rehabs to some extent ‘select’ those who they admit to treatment, for very good reasons, so the groups entering rehab and methadone treatment within these “naturalistic” treatment outcomes studies are not strictly comparable. This needs to be borne in mind when looking at the results of these studies. For example, in NTORS they differed on the proportion abstinent at entry, which puts a slightly different complexion on the results: the percentage of residential clients who were abstinent from illicit opiates increased from 19% at intake to 47% after 5 years (an increase of 28 percentage points) and for methadone clients from 6% to 35% (an increase of 29 percentage points). The findings show that both settings were successful at achieving abstinence from illicit opiates for a proportion of the particular group of clients with which they were engaged.
  
  As indicated in methodologically robust NICE and Cochrane reviews, there is good evidence that a range of treatments, including substitute prescribing, abstinence based residential rehab and psychosocial interventions can lead to a range of positive outcomes for some people, including less use of illicit drugs, improvements in health, reductions in crime etc. However, there is less evidence about which interventions are most effective, for which groups, under which circumstances, and how these can be incorporated into individualised recovery-oriented packages that improve outcomes across the board. This needs to be the focus of research and service development into the future.
  
  Nicola Singleton, Director of Policy and Research, UK Drug Policy Commission

• 

  written on 23-Oct-2008

  McKeganey says:

  In response to Nicola Singleton's point I would like to add that in the Drug Outcome Research in Scotland study we examined the level of drug dependence experienced by those recieving residential rehab compared to those provided with methadone. In fact there was very little difference between the two samples with the residential rehab clients slightly more drug dependent than those on methadone using the severity of dependence scale. In this instance then there was no suggestion that the much greater rate of abstinence on that part of residential rehab clients was to be explained by the fact that they were starting off with much lower levels of drug dependency than those treated in the community. The importance of ensuring the availability of a broad range of treatments that Nicola draws attention to is well made. Indeed it is in part for that very reason that we should be so concerned at the unwarranted diminution of the residential rehab sector within the UK.

• 

  written on 23-Oct-2008

  DeirdreBoyd says:

  Nicola Singleton is selective in her view of NTORS findings.
  First, she ignores the fact that more complex, chronically dependent patients were referred to rehab.
  Second, she ignores that 40% of people on mehtadone maintenance became dependent on alcohol.
  Thirdly, it seems that she lumps rehabs and NHS detox/inpatient together under the one heading of "residential" for results - in fact, the NTORS research showed that the detox units in its remit could actually cause harm; if the approaches were separated out, the residential treatment units/rehabs would indicate even more successful results.
  Finally - this is NOT about abstinence vs methadone so much as prevalent bad practice dispensing methadone inappropriately rather than MM within responsible psychosocial settings used by successful research.

• 

  written on 23-Oct-2008

  tim1leg says:

  Thanks McK, not only is it important to say what one feels and believes to be the case, but in order for me to recover and heal i have to be rigourously honest, this can cause difficulties but i am learning all the time who to share my views with, its such a shame the field cannot take the sprint to unite away from the old orthodoxy, but I suppose this enivitable slog is progress albiet it frustrating and at times damaging. Thanks again for your kind words of support and thanks again to everyone who has contributed to this.

• 

  written on 24-Oct-2008

  DavidClark [http://davidclarkwired.blogspot.com/] says:

  Nicola Singleton says, 'However, there is less evidence about which interventions are most effective, for which groups, under which circumstances, and how these can be incorporated into individualised recovery-oriented packages that improve outcomes across the board. This needs to be the focus of research and service development into the future.'
  I feel that this statement is a distraction from the main points.
  We certainly know enough to say that residential rehab is being disgracefully under-utilised, and that substitute prescribing without other adequate support is being over-utilised. To argue otherwise smacks of a political agenda.
  An excellent blog Kathy and some really good points from McKeganey and others.

• 

  written on 24-Oct-2008

  McKeganey says:

  I think that one of the most regrettable aspects of this debate, both within Kathy's blog and elsewhere, is the fact that the residential sector itself has not, for the most part, felt able to contribute. Their reticence in this respect cannot be because the issues being discussed are not central to their field of concerns and is more likely to derive from a concern not to endanger their already dwindling funding. If this is the case then we have created an environment in which to contribute to public and professional debate on these important matters is seen as a carrying a significant risk for ones welfare and the welfare of ones organisation. That is a culture more associated with single party political states than a healthy pluralistic democracy and it is something that we should seek to change though debate and the healthy exchange of ideas.

• 

  written on 24-Oct-2008

  DavidClark says:

  My impression from talking to people working in this field is that many are frightened to speak out, in case it jeopardises their funding. This is a very sad state of affairs. Might it be the case here?

• 

  written on 24-Oct-2008

  DeirdreBoyd says:

  Prof McKeganey is correct in that the treatment providers are afraid to speak out - they have staff and patients to protect. Too many have told me that they fear losing referrals if they publicise bad practice in commissioning (purchasing) treatment for people desperate to get off drugs and turn their lives around. Others, who do not have client referrals, fear never getting them. And so we, underfunded organisations not financially dependent on the state, by default advocate on their behalf.
  
  But I wonder if we have blamed the NTA incorrectly? Certainly, it takes credit for "202,000 people in treatment" (define treatment!). But it also states that the disproportionate 2% of referrals to drug-free rehabs is not its fault. Rather, it cites the PCTs/Department of Health and Local Authorities who hold the budgets.
  
  The first question this raises is the relevance of the NTA. It has drawn up excellent models; work over. Someone independent needs now to monitor the figures, someone who can apply sanctions, someone who actually knows what it needed.
  
  The second questions relate to the PCTs/DoH and LAs. Is the appalling track record down to Nick Lawrence, head of alcohol, drug and tobacco policy at the DoH? When I asked him this summer about only 3.6% of people being referred to rehab, he responded that the others did not want drug-free treatment!!!!!!! He is implying that 96.4% of people seeking help to get off drugs really do not want it. I think I am also correct in saying that the £54million+ of Tier 4 funding being allocated is in his remit. The guidance letters from him for applications are addressed to NHS PCTs, not to rehabs. Have any rehabs got any funding from this largesse?
  Also, the NTA is ultimately accountable to the DoH - is this again Nick's remit?
  
  Is it the DoH, already heavily criticised for the state of the NHS and NICE, which is depriving people of drug-free treatment? Let's have some clarity and accountability to the people who pay their salaries through our taxes.

• 

  written on 24-Oct-2008

  UKDPC says:

  David Clark says: "We certainly know enough to say that residential rehab is being disgracefully under-utilised, and that substitute prescribing without other adequate support is being over-utilised. To argue otherwise smacks of a political agenda."
  
  We can reassure David that UKDPC is not arguing otherwise (and it certainly does not have a political agenda). It is clear that the main point of Nicola's blog entry is to question the use of NTORS and DORIS research to show that "rehab is much better at getting addicts drug free", when these studies were not designed to compare different treatment modalities.
  
  Ben Lynam, Head of Communication, UKDPC (Nicola is out of the office today).

• 

  written on 24-Oct-2008

  McKeganey says:

  Actually Ben the DORIS (Drug Outcome Research in Scotland) although not an RCT was designed to look at the impact of different treatment modalities including comparing the rates of recovery (defined in a variety of ways including total abstinence) associated with the different treatment modalities available in Scotland.

• 

  written on 24-Oct-2008

  DavidClark says:

  Ben, I am not accusing the UKDPC of 'arguing otherwise'. But there are individuals and organisations who are.
  However, Nicola's point does distract away from the main thrust of Kathy's blog.
  We need to get on the same platform and argue for a greater use of residential rehab. This is not happening anywhere near enough.

• 

  written on 24-Oct-2008

  DavidClark says:

  I have just received a comment you might like to look at on my blog (Anonymous comment 4).
  Apparently, by supporting Kathy's efforts to help residential rehabs (my words) I 'may alienate the cause and value of your arguments to ally yourself in this way!!' (i.e. to Kathy, the Tory party, and David Davis's (Monmouth) outrageous comments).
  Sad that people resort to such petty, loose associations and hide behind anonymity.
  
  https://http://www.blogger.com/comment.g?blogID=48459 ... 85842
  

• 

  written on 24-Oct-2008

  Yenwarp says:

  As an addict in recovery, I am warmed and encouraged by McKeganey and your comments, a good ending to the week, I have had to go into 2 Re-habs since 2001 to reach this stage of recovery, some i know needed Re-hab 3 to 4 times, yet sadly! both Re-habs I went into I struggled to come to terms with my past due to many other residents their for the wrong reasons, a chose of prison or Re-hab, keeping your children, being re-housed or unavailable for futher prosecution,(I could go on) that is a sad fact. This annoyed me as I know even more so now, there are many addicts desperate for Re-hab for the right reasons, "They, like myself! do not want to be labelled once an addict always an addict!" We really wanted to be free of our drug of chose and for many of us Re-hab is the only chose, yet to many individuals from professionals to lay man believe Re-hab doesn't work. The inspection of Re-habs today to meet criteria is rigid and out there today Re-habs offer the best if not the only chance for us addicts to save our lives. There not holding pens yet there for the serious addict to once and for all have a real chance in becoming abstence free from any mind altering drug. A first and brave step towards recovery. So having been there and here to write this, Re-hab does work, funding should be more readily available and in the long run it saves more lives than treatment in the community and the cost justifies further available funding than what presently is available.

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