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Recovery from drug dependency: where next?

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Today Public Health England published national drug treatment statistics for adults in 2012-13. They show that treatment continues to perform well overall and that, within the context of declining prevalence, the numbers in treatment are falling.  Access remains quick and easy for anyone who needs help with a drug problem.

However, after an increasing trend over recent years in the proportion of people successfully completing drug treatment, we are now seeing that proportion begin to level off.  Treatment is now dominated by older heroin users; this group, with entrenched addiction and multiple problems, is particularly hard to treat and this makes further progress on recovery rates more difficult.

So what do we know about how best to support people into lasting recovery? Where are we in terms of achieving our recovery ambition for people in drug treatment? And, in the context of the statistics released today, what can local authorities do to continue the momentum and support recovery in their areas?

Drug dependence is a complex issue. A range of factors is involved, including the individual, the drug, patterns of use and social determinants. Severe dependence is often complex and long term, and often characterised by cycles of relapse. The majority of those in treatment in England are heroin and crack cocaine users; many have been using for a long time and as they get older are experiencing chronic health problems. Recovery for these people can be incredibly hard, however many have made remarkable recovery journeys and now lead full and accomplished lives. It is also significant and positive that recovery is becoming much more visible in our society, demonstrated in part by recent well attended recovery walks.

A great deal was achieved over the last 10 years by drug treatment in England in reducing harms for individuals and communities. Perhaps because of the size of the task and the considerable benefits achieved in these domains, it took some time for a focus on achieving social integration as the goal of drug treatment to emerge. But emerge it did, with the rise of the recovery movement in the field from around 2005 and culminating in the Government’s 2010 Drug Strategy.

Like drug dependence, recovery is a complex concept.  While what constitutes recovery may be a subjective judgement, clearly it needs to be an individual and an individually-owned journey. We need to acknowledge, respect and support the full spectrum of beliefs and methods that people may choose to adopt to achieve recovery.

The challenge in essence has been to increase the focus on the ‘psychosocial’, and particularly the ‘social’, components of the bio-psycho-social approach to dependency. Involving families and broader social networks of support, including mutual aid groups such as the twelve-step fellowships and SMART Recovery, has been and remains a priority. There is much practitioners can do in terms of facilitating access to these groups, and much local authorities can do to foster communities of recovery, through an asset-based approach. Many areas of the country are beginning to achieve success with this.

Pharmacotherapy also has a strong evidence base and an important role in recovery.  The work of the expert group chaired by Professor John Strang, culminating in its 2012 report ‘Medications in Recovery’, made an internationally recognised contribution to realising the appropriate balance between the different components of treatment.

Looking ahead, while protecting the health and community safety achievements to date, we need to focus on social integration and wellbeing. It is encouraging that many drug treatment services are using the five ways to wellbeing and incorporating them into thinking about care planning. The stigma associated with dependency is also an important issue, and PHE must have a clear voice in combating it.

Recovery, as with wellbeing, is mediated by someone’s access to social or ‘recovery’ capital. Alongside treatment, access to stable housing and developing the wherewithal to be work-ready are vital components. This is where the transfer to local authorities of responsibility for drug treatment presents the greatest opportunity in my view. They have a genuine opportunity to link services to provide properly integrated responses to drug dependency and we will be supporting them to realise this ambition.

Drug recovery is one of PHE’s top priorities.  To support our efforts and thinking in this area we have appointed the addictions expert Professor Tom McLellan to provide us with clinical and academic advice, from an independent international perspective, on how we can most effectively lead in this area.

Evidence tells that not everyone will recover, particularly those who experience the greatest health and social inequality. As we see the numbers successfully completing treatment level off, are we actually beginning to reach pinnacle of what can be achieved? At PHE we believe there is still further to go if we hold onto our ambition and if everyone is given the best possible chance of recovery.

We have a robust evidence base for the fact that the way in which pharmacotherapy, psychosocial interventions and integration pathways are delivered has a significant impact on outcomes. Until everything local areas do to drive recovery is aligned with that evidence, there is still some more road to travel.

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  1. Comment by Sara McGrail posted on

    Its surprising that PHE do not actually have a little more information on hand about what actually is happening in treatment services in the name of recovery. The appalling clinical practice in some areas is leading to premature and compulsory detoxification and the withdrawal of clinically mandated services to meet central targets. (Lets remember here the only target that actually matters in terms of this alleged top priority is being out of treatment for 6 months. In this context death is a successful outcome). You do indeed have a very robust evidence base for effective treatment, but drug services just like sexual health services are commissioned outside any robust clinical governance framework, sit outside the Monitor regulations on commissioning and are a very very low priority for CQC. This blog would be laughable in its naivety if it were not for the fact that people are actually beginning to die from the disgraceful way this policy area is being managed by PHE. Shame on you.

  2. Comment by Alliance posted on

    There are a few significant issues with the claims reported in this article.
    On a daily basis we receive both calls and emails from people wishing to stay in drug treatment, however their treatment is being withdrawn or made untenable in a number of ways. This does not reflect success in terms of impact on individuals drug use, quite the opposite with many returning to illicit markets. What it does reflect is the drive to achieve targets, not by effective practice and treatment but by identifying those that can be more readily pushed to leave services and achieve national/local targets. Often it is reported that this is being undertaken in either PHE's name or that this is Government policy.

    While we know that there are good practitioners out there, there are also a number that cannot effectively work with this group. When I say this group this is of course a generalisation. There are a number of groups of people using a growing range of drugs, however no services are really being provided to them. The article refers primarily to those in receipt of opiate substitution therapy and not to opiate users within society more generally. One cannot conclude that people leaving treatment equates to a reducing number of drug users nationally. That is a logically bizarre claim to make. Our experience suggests that many of those leaving treatment feel forced to do so and are swelling the ranks of those involved in illicit markets.

    This kind of sound bite manipulation of people's views is made even easier now that commissioning of these services (along with sexual health services and some health visiting), are removed from any form of regulation. Commissioners are now free too (and do) specify a percentage of the treatment population that are to be removed from treatment within any financial year with significant financial penalties if not achieved. So much for "evidence based treatment" and NICE guidance. Such payment by results targets are having a devastating impact on individuals lives with the treatment industry focused on money rather than lives. I know of no other area of social/medical care where success is measured by the absence of people in treatment or where that absence is financially rewarded. This is a national disgrace and we call on PHE to look into what is ACTUALLY happening and apply both professional standards and responsibility for work conducted in their name.

    Ken Stringer
    The Alliance

    • Replies to Alliance>

      Comment by Kevin Fenton posted on

      Most people come into treatment wanting to quit drugs and rebuild their lives. Our collective job – PHE, local authority commissioners and treatment services – is to help more of those who are ready to recover to achieve this. While there can be no perfect proxy for performance on drug recovery, the measure of successful completion does at least reflect the goal of all treatment – to help people overcome their dependency. There is no national target for drug recovery, and no financial incentivisation of local authorities in relation to successful completion rates.

      Clearly both poor commissioning and poor clinical practice are unacceptable. We are keen to hear of specific evidence that people are being pushed out of treatment earlier than they should be, particularly in order to massage local performance figures. PHE will assist in cases where a service user feels aggrieved about their treatment, where necessary using the appropriate governance and regulatory channels.

      • Replies to Kevin Fenton>

        Comment by Alliance posted on

        Thank you for your response Kevin

        In what form would you like the evidence? How much of it? How do we establish a dialogue regarding this?

        I would also be keen to appreciate the regulatory framework that covers this area of work. Clearly CQC has a role to play where standards are not being met, especially in terms of safety. However, whenever we look at who has any effective regulatory role around commissioning via local authorities we hit a brick wall.

        We are keen to establish protocols and routes of communication so that we may assist in challenging bad practice brought to our attention (on a daily basis). How do we proceed?

        best wishes


        • Replies to Alliance>

          Comment by Alliance posted on

          May I also add that people come into treatment for many reasons, some are forced to, others to get away from illicit markets and others to stabilise their lives with giving up drugs a possible long term aim. The view that "Most people come into treatment to quit drugs" does not help to understand the needs of what must be a sophisticated treatment and support system. To plan on the basis of that assumption will certainly minimise any impact on drug related harm nationally.
          One other area of concern is the amount of time we spend supporting people that wish to become drug free, that cannot access detox or rehab where it is appropriate for them. It is a bizarre time we live in where some providers are forcing people out of treatment programmes while some others refuse to let people even reduce. We need to see a drive to have service users views and wishes respected in this regard and for them to be afforded the dignity of being proactive within their own recovery

        • Replies to Alliance>

          Comment by Alliance posted on

          Hi Joe

          It hasn't been proven as incorrect, the evidence hasn't even been effectively challenged either.
          In the "putting Full Recovery First" document, among the other opinions contained within it was the view that new evidence should be created. If you have not read it it can be found here
 Please note I am not promoting this document, it is dangerous. Although drugs/alcohol are shown against PHE/Health I suspect that they are not actually running the show, I am confident that things might be a little different if they were. Welcome to the world of smoke and mirrors.

      • Replies to Kevin Fenton>

        Comment by Sara McGrail posted on

        I am terribly sorry Kevin but you are wrong. In the circular that accomanied the treatment allocations for drugs and alcohol for 2012/13 (which I believe is this year) the following is stated very clearly:

        "20% of the overall allocation is based on the activity as defined by the number of adult drug users that had successfully completed treatment and who had not re-presented to treatment anywhere in England for at least six months."

        Do you think, perhaps, you might get your facts straight?

        • Replies to Sara McGrail>

          Comment by Kevin Fenton posted on

          Thank you. The facts are as follows: 2012-13 was the final year of the Pooled Treatment Budget, which included a component that rewarded local authority performance on successful completions. With effect from the current year, 2013-14, local authorities receive a public health grant to fund all their spending on public health including drug and alcohol treatment; funding for drugs and alcohol is not ring-fenced and it is for local authorities to decide how much of their grant to allocate to this area.

          • Replies to Kevin Fenton>

            Comment by Sara McGrail posted on

            That's fascinating Kevin. Maybe you could explain why in the Exposition Book for the 13/14 Ringfenced Public Health Grant its talks about a 20% allocation based on treatment completions, 24% on need and 56% on population? Perhaps also you could explain the existence of the Public Health Outcome Indicator 2.15 Number of Successful Completions.

      • Replies to Kevin Fenton>

        Comment by Sara McGrail posted on

        "To reinforce this, and as forewarned last year, the allocation formula for the adult PTB now includes an element that incentivises local systems to become more recovery focused. Twenty per cent of the allocation has been linked to the numbers of individuals who successfully completed treatment the previous year and did not then return."

        (Paul Hayes "Recovery funding for 2012-13" Letter to Drug Partnership Chairs, Joint Commissioning Group Chairs, Joint Commissioning Managers, DAT Coordinators, 24th February 2012 Gateway approval ref 17257 Paragraph 6.)

        Hope that is useful.

  3. Comment by Sapphire posted on

    As a service user, I must say that what PHE are claiming does not equate to what is actually happening in drug treatment.

    People are exiting treatment primarily because they are being bullied out of it by their DSP.

    What is the point PHE, in getting people off methadone and buprenorphine, if they are just going back to active addiction because of the incessant hoops that drug services are making them jump through.

    The Orange Book says that all treatment must be user led, and that treatment that is forced upon the user is unlikely to be successful, so why are DSP's employing bully boy tactics to get vulnerable people, often with severe mental or physical health conditions, out of treatment?

    The drug treatment system in the UK used to be one of the best in the world, yet now we are forcing people out of treatment. To make the figures look good and to appease the right wing government and its' voters?

    People with physical drug addiction problems are being treated in the medical ghetto. If we were any other group of patients (diabetes sufferers for example) there would be complete uproar at the way we were treated. Yet because we are addicts, according to this government, we do not get a say in OUR treatment.

    This is causing people forced out of treatment to die of overdoses and an increase in the incidences of blood borne virus's.

    I believe that PHE need to look more closely at what the drug service providers in their remit are doing, and bring an end to people being forced out of treatment just to make the numbers look good.

    • Replies to Sapphire>

      Comment by Sara McGrail posted on

      The single most important thing government could do is remove the financial incentive to take people out of treatment. In a time of austerity this is critical for commissioners as even those who know how dangerous this approach can be will be under pressure from local partners to maximise income.

  4. Comment by Alliance posted on

    Also an immediate and clear public message to service users, commissioners and service providers that removing people fro their chosen recovery path IS NOT Government policy, unless of course it secretly is?

    • Replies to Alliance>

      Comment by Alliance posted on

      Thank you for your response above in which you state "There is no national target for drug recovery, and no financial incentivisation of local authorities in relation to successful completion rates." We are heartened to hear this, however we are seeing arbitrary targets being set as PBR targets across the country, some as high as ensuring 50% of service users exit treatment within any financial year. This is clearly being stated as a PHE and Governmental approach. Would you ensure that any communication to service users, commissioners and service providers emphasises the point that you have made above and that arbitrary reductions are against national standards? We are happy to assist with this in anyway that we can. It would also be helpful if you could supply us with a letter we may use to challenge providers that currently state that removing medications is Governmental policy.
      Thank you in anticipation


  5. Comment by Sara McGrail posted on

    In terms of those claims about no incentives or targets for drug recovery Kevin, I wonder if you could square this for me with the recommendations from the National ASids Trust report on HIV and injecting Drug Use from July 2013 based on consultations with amongst others Department of Health (John McCracken) and PHE (Pete Burkinshaw) which stated that: -

    "Current policy and financial incentives around drug treatment outcomes inappropriately and dangerously focus solely on treatment exit. The Public Health Outcomes Framework needs at the very least to balance the treatment exit indicator with indicators around drug-related deaths and HIV and hepatitis C transmission."

  6. Comment by Sara McGrail posted on

    And finally can I also draw your attention to the document "Putting Full Recovery First" published in 2011 jointly by DH and a number of other departments which identifies governments intentions regarding the incentivisation of "recovery" by unequivocally stating that the aim of policy was to establish a system where treatment providers will be paid ONLY for abstinence outcomes (clearly identified as total abstinence - eg abstinence from legal, prescribed and illegal drugs):

    "Creating a recovery-oriented treatment system means offering people the right treatment and support at the right time. Such reform, and improvement in people‟s lives, will also deliver much better value for taxpayers‟ money in the short and longer terms as ultimately payment will be made for full recovery only." PFRF 2011.

  7. Comment by Neil Hunt posted on

    I find it difficult to reconcile this statement:

    “Like drug dependence, recovery is a complex concept. While what constitutes recovery may be a subjective judgement, clearly it needs to be an individual and an individually-owned journey. We need to acknowledge, respect and support the full spectrum of beliefs and methods that people may choose to adopt to achieve recovery.”

    With this one:

    “Drug recovery is one of PHE’s top priorities. To support our efforts and thinking in this area we have appointed the addictions expert Professor Tom McLellan to provide us with clinical and academic advice, from an independent international perspective, on how we can most effectively lead in this area.”

    And this one:

    “Evidence tells that not everyone will recover, particularly those who experience the greatest health and social inequality. As we see the numbers successfully completing treatment level off, are we actually beginning to reach pinnacle of what can be achieved? At PHE we believe there is still further to go if we hold onto our ambition and if everyone is given the best possible chance of recovery.”

    I absolutely endorse the first reference to an “individual and an individually-owned journey”, yet it is almost impossible to meaningfully operationalize and evaluate this within research because of the ‘individual’ nature of the implied outcomes. Furthermore, in the context of a national strategy that defines ‘recovery’ in terms of abstention from illegal drugs and local commissioners who use performance indicators in contracts to push services to abbreviate substitution treatment (in direct conflict with the clinical evidence and guidelines for its effectiveness), it seems impossible to interpret the second and third quotes in any other way than with a sub-text that equates recovery with being drug and medicine free. Something that I find either disingenuous or naive.

    You ask the question “Recovery from drug dependency: where next?” To me, much of the debate around ‘recovery’, what it is, what it isn’t and so on seems a divisive distraction from some obvious deficits in our public health response to drug use. Here are just two examples with clear implications for public health:

    1) HCV treatment for people who inject drugs.
    We have many people with HCV who do not currently get treatment which could: a) benefit their well-being; b) reduce long-term healthcare costs; and, c) reduce new infections i.e. ‘treatment as prevention.’ Yet, nationally our HCV treatment coverage rate for current and former injectors is a shameful disgrace. We smugly congratulate ourselves on our impressive performance-target driven ‘HCV testing’ rates, whilst tragically forgetting why it is so important to offer accessible testing – as a first step to effective treatment that can improve people’s health and well-being. Such irony could come directly from the script of political satire such as ‘The thick of it’.

    2) Take Home Naloxone.
    Through the peer-reviewed evidence base, NTA pilots and experience within assorted local programmes in England, Wales and Scotland, we know that this cheap antidote has successfully reversed thousands of heroin/opioid overdoses when it is provided to the people most likely to be present and able to respond rapidly to an overdose – people who inject drugs themselves. Yet although England is an epicentre for overdose deaths in Europe, we completely lack a coherent approach to this life-saving intervention. So if you are an injector who lives in Plymouth you may have an excellent, accessible service, but if you live in Peterborough you quite possibly haven’t even been told about naloxone, let alone offered it.

    So from these examples, where next?

    1) Greatly increase the promotion and access to HCV treatment for current and former injectors and ensure there is transparency about the present, serious inequalities in coverage and quality between localities.

    2) Promote ‘Take Home Naloxone’ as an essential component of all local drug strategies and, again, ensure that public health decision makers and advocates are able to compare local provision and identify both excellent and poor quality public health responses.

  8. Comment by Joe Bloggs SU / Practitioner posted on

    'A great deal was achieved over the last ten years'. Yes it really was. And now it is being dismantled under the guise of 'Recovery'. Nothing could be further from the truth. How do I know? Because I'm both a service user & a very experienced and well qualified drug worker. I see both sides of the coin very well from a fairly unique viewpoint. I am a product of the early part of the century's drug treatment policies - an entrenched, poly-drug using opiate dependent user. For the first time in my drug-using lifespan, I was able to access methadone maintenance...the way it should be, without artificial 'goals'. You stop when you are ready. When life lets you stop - life is a tricky business. But now, it doesn't matter - I have to be 'abstinent'. Oh the irony - my script kept me stable, really stable. Now, I am told by heavy drinkers (drug workers) that 'it's about time'. Never mind that this works for me. I mean, really works. I function, don't go off the rails, and do a bloody good job as a substance misuse worker. But, no, now I MUST come off - right now. Never mind the excruciating stress I've been through that would break lesser people. I MUST come off, & come off now. Never mind that I'm a whisker away from completing a Degree in this field. Never mind that I can't cope. (You would never dream of doing this to someone on anti-depressants - but it's the dreaded 'M' word). And, so to work. I never thought that all my OST clients should go down the maintenance path, only for the very few, like me, that it works for. A long track record of getting people off meds and into work. Now replaced by bullshit soundbites. Drug work outta manuals. Hijacking 'Recovery' - remember that the UK Recovery Foundation distanced itself from the Govts Roadmap White Paper? Nothing about us without us?? Nah, mate...back to the 'good old days' when drug workers knew best. (How?) You might think this is a rant and in a way it is. But rants offer capture the essence of what's might read this & think 'what a load of bollocks'. God knows. I could sit here and right a very well written, well evidenced & referenced essay on why drug treatment has gone backwards in a big way. But, you know what - I can't be bothered - not because I don't care, but because I can't carry on splitting myself in two - trying to do a good job whilst ticking the requisite boxes. As a long time experienced, 'on the ground' worker, I will tell you what many others (hopefully) would - we are drowning in doublespeak, meaningless old rubbish in a tick-box, target-driven world. I could bear most of that if I didn't spend (VERY accurate estimate) 75% of my working week pushing clients & stats about on a computer screen - how can that ever be right??? From a worker's point of view - rubbish. From a client's point of view - Rubbish. From one furious service user & drug worker....RUBBISH !

  9. Comment by Alliance posted on

    Thanks Joe, we see many comments like this very frequently and appreciate the courage that both yourself and Sapphire have shown in making your points within what has become after all a punitive regime for many

    • Replies to Alliance>

      Comment by Joe Bloggs SU / Practitioner posted on

      Thank you very much. I was seriously going to ask the mods to remove that as it was just a very peed off rant to be honest. But there is truth in there. For example, of course I'm not saying that all drug workers are hard drinkers; but by the same token I know that so many of my colleagues up and down the country are knocking back alcohol to deal with the stress and the bull**** of pushing clients around on paper to meet untenable targets and demands.. That is supremely ironic in my book. Substance misuse work has been dumbed down unbelievably. If anyone seriously believes levels of drug use are falling then they need their head examining. Anyone in the field knows how these figures and 'facts' come about. Why in God's name have we treated the last ten years or so as a failure? It really is beyond me. What we should have done is re-grouped, re-evaluated and built on those successes. Of course there are failures in there, and we could have learnt from them. I'm an avid Harm Reductionist, yet I can clearly see areas that could have been improved upon. But why oh why throw the baby out with the bathwater? Not just out, but out the window into the street. I'm only stating the bloody obvious, but we are not working from a new evidence base. We are not working from new Clinical Guidelines. This new 'approach', for want of a better word, is totally ideologically driven; even worse, not expertly ideologically driven. Actually driven mainly by opinion, largely by the 'Centre for Social Justice'; an oxymoron if ever there was one. Methadone and buprenorphine maintenance treatment works for so many people. I don't have to reference the evidence, it's already there for God's sake. 12 step works for many, many people. None of this has to be mutually exclusive, as anyone who has worked in a decent treatment service can tell you. Ten years in this field has taught me that proponents of different ideologies can operate under one roof and still provide almost gold standard treatment, which is hardly what is on offer now. I wholeheartedly applaud the work that many in the Recovery movement have done to bring together two ideologies that used to compete with each other. As a Harm Reductionist, something that strikes me about AA etc is their total independence from government funding / interference. Their domain remains unpolluted by the ideological fads of those who have not a clue. Mainstream treatment has had to bow down at the feet of central govt, with devastating results. I have yet to come across a single worker of any ideological bent who thinks things have got better under the new agenda, and I am very open to the views of others.
      Our industry has fallen prey to charlatans and snake oil salesmen offering gobbledegook 'treatment' or 'training' regimes that will 'cure' clients within the mandated target times. These people are getting rich off the back of an industry desperate to survive under the constant attack of demands that simply can't be met. What a crying shame; British drug treatment has often been amongst the best in the world. Had we continued to build upon the successes of the last ten years, we truly would be world leaders.
      Kevin, if you read these posts, I really hope you take them on board. I've noticed that so far I'm the only practitioner who has commented (I think). That's because we currently live in a climate of fear; we all need our jobs in times of austerity. Being opinionated is not encouraged these days.I have only commented as I am at the end of my tether and despair at seeing the job I love systematically dismantled and destroyed for the sake of targets. How short sighted! Money may be saved to start with, but the 'total cost' will be very high.
      When the smoke finally clears and we can no longer sustain the illusion of success evidenced by such dubious outcome measures as TOPS, we will have all the work in the world to do to re-build something that was already there all along.....

  10. Comment by Joe Bloggs SU / Practitioner posted on

    My final comment is just to clarify some points in my original post; after reading it back in the cold light of day I can see a couple of mistakes, or points that could be read as arrogance.
    What I was trying to get across was feelings and emotions from both a client's & worker's viewpoint of the last ten years or so. When I referred to 'stress that would break lesser people' I was referencing the total lack of empathy that comes across to a client desperately trying to hold onto to a truly life-changing medication at totally the wrong time to reduce and come off a script.
    I don't believe anyone to be a 'lesser' person than me; this was just an example of gut emotions that come out when you are being forced (and I do mean forced) to come off a medication that has enabled you to leave a life of crime and black market enterprise and become a 'productive member of society' for want of a better phrase. It is truly soul-destroying to be pushed off a script that was originally prescribed without the premise that it would eventually be withdrawn at some arbitrary time, in fact the worst possible time to do so in my own case! I think it was Sapphire who commented that official Clinical Guidelines (i.e. expert and evidenced based guidance) support user-led targets in regard to when one decides to reduce. This is the exact opposite of what is happening!
    Let me be clear here Kevin - I, like many others, AM BEING FORCED to come off my script.
    I also stated that OST maintenance works for 'very few' people. That is totally incorrect - it works for many, many people. I was just acknowledging that it doesn't work for everyone, and that a worker on a maintenance script would not be arrogant enough to try and push what works for them onto others. At work I treat clients as individuals. Every single person I work with is unique in their own right; for treatment to be successful it has to acknowledge that fact. It cannot work with a 'one size fits all' approach.
    Many ex-users such as I can attest that much / most of the treatment offered in the 90s (punitive with arbitrary time targets and sub-standard dosing) was a waste of time, and they either never accessed treatment, or 'failed' in treatment because of these regimes. Now these regimes are back under the guise of 'Recovery'. Many who have 'successfully completed treatment' have in fact been forced off OST scripts and are sadly back where they started. But, hey, who cares as long as outcomes are 'successful'. As Sara McGrail pointed out, death is a successful outcome under these regimes and targets!
    We are failing, and failing big time. I cannot phrase this any other way. Others have commented so accurately on research and policy failures that totally contradict PHE statements. I cannot match their accuracy and expertise in this regard, which is why my rant was aimed at capturing the emotions from both a worker's and client's viewpoint.

    'Recovery' was offered all along. You cannot own it for others. It belongs to those who actually recover, It also, in part, belongs to those who helped to facilitate it, and you cannot neatly package it into manuals and meaningless and factually incorrect political sound-bites.

  11. Comment by Sara McGrail posted on

    "'Recovery' was offered all along. You cannot own it for others. It belongs to those who actually recover, It also, in part, belongs to those who helped to facilitate it, and you cannot neatly package it into manuals and meaningless and factually incorrect political sound-bites."

    That puts it really well Joe. There are just a couple of things I wanted to add to what you've said. I do not believe the first ten years of this century was necessarily a period of success for drug treatment services. It was a time when there was lots of money - yes. And critically there were some important steps towards crystallising the evidence base for substitute prescribing. However, it was not a period when harm reduction was the dominant paradigm - in fact it was a period during which the UK moved quite dramatically away from good public health practice. The dominant paradigm was demand reduction. This was when we saw targets for numbers in treatment, arbitrary retention targets and what others have described as "warehousing" on methadone. It was also an era when we saw quite dramatic decreases in investment in needle and syringe programmes and projects targeting non structured approaches at vulnerable out of treatment populations. It was also an era when we ceased to treat people and began to treat drugs. We saw the effective cessation of treatment in many areas for people using anything other than crack cocaine or heroin. Alcohol services were a poor relation of drug services.

    What we need is not a return to this demand reduction approach, but to evolve our understanding of this policy area to integrate a recovery focus with effective evidence based harm reduction approaches like universal access to nsp and naloxone. We also do need to begin to invest properly in treatment for some of the chronic conditions the people who use services can suffer from. I include in this as Neil pointed out the national scandal building behind the postcode lottery that is Hep C treatment, but also cirrhosis and of course the huge numbers who suffer from chronic mental health conditions but find them self thrown from CMHT to drug service like shuttlecocks in a particularly ill played game of badminton.

  12. Comment by mad and proud posted on

    Surely recovery is more than just being off drugs? Living more fufilled lives etc Surely then everyone has the potential to recover (grow) in someway. The PHE view seems to consign a hard core group of drug users to some kind of scrap heap. One could imagine how services would prioritise resources on people who can be more easily moulded into model citizens.

  13. Comment by Donald Macphee posted on

    Giving back in recovery is all about what helped you and how this can help others. Self actualisation is pivotal in my own recovery, knowing that I am helping others progress on their journey is reward enough.

  14. Comment by Joe Bloggs SU / Practitioner posted on

    Sara, thanks for that and I make you right on what you have said. Especially around HCV, and also I guess it was the start of the 'McDonaldsing' of all the small individual street-level agencies. I think I was one the lucky people whose life was turned around by MMT, and I became enabled to do many great (imho) things via the promotion of Harm Reduction.
    This good fortune was initiated by the provision of fairly good, target-free (for me) MMT. I say fairly good rather than excellent, as after a few years came regular hassle from keyworkers saying 'don't you think it's time to reduce?' This became worse as services became more incentivised to get people off scripts. I DO think you should be asked sometimes if you still want maintenance, but only as part of a care-plan review. That question was never put to me because it was a good time to ask it, and it was almost always very clearly influenced by moral judgement. The fact that long term, even lifelong MMT is very well evidenced as a gold standard treatment and should be patient-led, unfortunately seemed lost on those who rated their own moral compass more important than the plain old truth.
    For people like me now, those days seem halcyon in comparison. I could write a bloody essay on how MMT changed my whole life for the better.

    Kevin, people are being forced off their scripts up and down this country every day. For at least a large proportion of them this action will have negative, if not disastrous consequences. That is the truth.

    Can anyone please tell me when the evidence base for MMT / OST (long term as & when necessary) was empirically proved to be totally incorrect? How can it make any sense that we are ignoring one of the most powerful medical tools at our disposal?

  15. Comment by Bren posted on

    Hello Kevin,

    This blog has most certainly generated a number of thoughts and feelings. I read your blog and what I felt was that not all people would want to stay in treatment and the key would be to what support is there, across the social model to have the services meet the needs of the person.

    Thank you Kevin,

    Best wishes,


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