REHABILITATION WORKS: THE EVIDENCE
A myth is doing the rounds that there is no evidence that rehabs work – much like scientists could not prove until four years ago that bees could fly.
Deirdre Boyd gathers some of the evidence, and outlines the necessity to read the true figures behind detractors’ remarks.
Download Addiction Today 127 – Rehabilitation evidence
“There is a lack of evidence that rehab works” is a myth which the National Treatment Agency for Substance Misuse has been spreading for some years rather than identifying the evidence. Sadly, we have heard it even from Cabinet and other members of government who know people in recovery, know how they quit their addiction – but feel they cannot support successful methods until they are publicly proven. Well, the research is out there, and has been for quite some years.
What is more, the evidence base for rehabs and 12-step linked treatment is stronger than other forms on which money has been splurged these past nine years.
Of course there is a role for harm reduction, particularly as engagement into treatment/recovery. But UK practice became harm maintenance when it replaced treatment instead of complementing it.
WHO PAYS FOR THE RESEARCH?
Recruiting independent researchers to find clients and ex-clients, follow them for years with questionnaires and interviews, collate the information and verify it, then interpret the results is a long and costly task – it is costly even when inhouse staff undertake some of the work.
When Broadreach commissioned what was the largest survey into outcome predictors in 1994, we understand it cost over £100,000. Despite the importance of this work, and despite how financially punitive it is for rehabs, there has been little or no government support to gather this evidence.
And the NTA’s Top measurement tool is not suitable for rehabs – see below.
VERBAL VS EMPIRICAL EVIDENCE
The NTA Top measurement tool is self-report only. The outcomes are not independently verified, and research by Dr David Best and Dr Jason Lutty describe how they are not accurately filled in. Even if they were, Top does not measure methadone use or other addictive drugs such as ecstasy or benzodiazepines, so cross-addiction is invisible. In other words, reductions in specific drugs (symptoms) rather than the benefits which derive from full recovery (addressing causes) are noted. Despite these limitations, the NTA quotes Top/NDTMS self-report figures instead of worldclass rigorous empirical research.
WHAT DO WE MEAN BY ABSTINENCE?
When we read about “abstinence” outcomes in rehabs, it means abstinent from all mood-altering substances including alcohol. For patients to stay off all drugs, they must be working a psychosocial relapse-prevention programme which addresses causes and redresses behaviours. But in harm-reduction/methadone-maintenance services, it can be defined as abstinence from only one drug; old behaviours usually continue, as does relapse onto other drugs.
For example, in NTORS about 40% of methadone maintenance patients became dependent on alcohol, and references elsewhere to “ex-heroin users” can mean they are still using other drugs. It is vital to ask what “abstinence” means when you read any report.
It is also not understood that rehab staff and people in true recovery use shorthand when they talk about “abstinence”. They do not mean merely desisting from substances, but tacitly know that abstinence is sustainable only when behaviours and relationships are healthy (eg, with family), when relapse triggers are addressed, when childhood traumas are faced and no longer influence actions, when life is lived with honesty to self and others (no crime), when amends are made for past actions and a determination made not to create future problems, and a promise is made to help others suffering from addiction. Many clients train for a career, and honest living.
What research paper mentions all these outcomes in one word?
WHAT DO WE MEAN BY REHAB?
Usually, we mean treatment programmes of four weeks or more in a residential setting, where the therapeutic process of change is linked to steps in Alcoholics Anonymous, Narcotics Anonymous or other 12-step fellowships. This means that patients can join these free support networks for as long as they need, after they leave treatment.
However, there are some excellent daycare and ‘quasiresidential’ programmes using the same principles, the only difference being that the treatment provider does not offer accommodation. There are also sessional/private therapists who treat clients with these same principles.
Until we universally agree a better term, the word “rehabilitation” covers all these settings. What they have in common is that they help people give up their drugs of harm and better their lives, and sustain those benefits long term.
RESIDENTIAL REHABILITATION: GOVERNMENT REVIEW 2009
The government’s Commission for Social Care Inspection and the NTA jointly carried out a review of treatment services in 2008. “Residential rehabs outstrip other sectors in every outcome group we measure,” announced CSCI inspector David Finney.
CLOUDS INDEPENDENT RESEARCH
As long ago as 1995, an independent research psychologist was commissioned and allowed to select from any block of admissions into Clouds House rehab. Of 166 randomly chosen ex-clients, 61% were abstinent from all mood-altering substances 30 months after treatment.
Of the predictors of successful outcomes, two were important. First was discharge status: 82% of people completing the programme satisfactorily showed good outcomes at follow-up. Second, 89% of ex-patients attending 12-step meetings were abstinent at follow-up.
DORIS: DRUG OUTCOME RESEARCH IN SCOTLAND
December 2006 saw the publication of Abstinence and drug-abuse treatments: Results from the Drug Outcome Research in Scotland study. It followed 1,033 drug users contacting treatment services who were able to become and stay abstinent 33 months after starting treatment – and identified which services were most closely linked with such drug-free results.
The Doris researchers defined abstinence in terms of people being totally drug free (other than alcohol or tobacco use) for at least 90 days before their research interview. 29.4% of those in contact with residential rehabilitation services but only 3.4% of those in contact with methadone maintenance services had a 90-day drug-free period nearly three years after having initiated a new episode of treatment, the report stated.
NTORS: NATIONAL TREATMENT OUTCOMES RESEARCH STUDY
The largest UK research into outcomes of drug treatment came from the National Treatment Outcome Research Study, which published changes in substance use, health and criminal behaviour during the five years after intake.
The NTORS authors note that “Clients in the rehabilitation units included the more chronic, long-term users with the most severe problems. Rehabilitation clients presented with the longest heroin careers, they were more likely to be regular users of stimulants (especially cocaine), and were more likely to have shared injecting equipment. There were also more heavy drinkers among the clients entering the rehabilitation programmes. Rehabilitation clients were more likely to have been actively involved in crime and they had been arrested more often than the other clients.”
Despite this, over 38% of the “residential clients” were abstinent from six illicit target drugs 4–5 years after treatment compared to 35% of methadone clients. The gap is greater than it at first appears.
Methadone users were described as abstinent when using not only that drug but also if using psychoactive drugs other than “illicit heroin, nonprescribed methadone, crack or powder cocaine, non-prescribed benzodiazepines and amphetamines”. So they could still be using prescribed heroin, cannabis, ecstasy…
Second, the NTORS researchers bafflingly mixed up NHS inpatient/detox outcomes with residential rehab instead of separating them out, even though anecdotal evidence is that the former have little success (so bad in one notable case that it led to a call for retoxing clients before releasing them) and the latter far greater success rates.
Thus we can conclude that the successful outcomes for residential rehab are higher than the 38% quoted in NTORS.
DOES TREATING PEOPLE INCREASE THEIR CHANCE FOR ABSTINENCE?
This study followed 269 people in full (abstinent) recovery. “The only type of formal treatment service which was a key factor in helping drug users to stay abstinent was residential rehab”, found researchers Dr David Best, Jessica Loaring and Safeena Ghufran. “Formal long-term structured (not rehab/TSF) treatments played only a peripheral role in the recovery journeys.”
PREDICTORS OF 4-YEAR OUTCOME OF COMMUNITY RESIDENTIAL TREATMENT
Predictors of 4-year outcome of community residential treatment for patients with substance use disorders, published in 2008, examined systematically how predictors of substance use treatment outcomes worked in over 2,000 male patients. “Greater substance use severity, more psychiatric symptoms, more prior arrests and stronger belief in AA-related philosophy at treatment entry predicted improvement significantly in substance-related problems four years later. “At the one-year follow-up, being employed and greater use of AA-related coping predicted outcome significantly,” the research confirmed.
THE GUIDE TO REHAB – WHAT REALLY WORKS
20 research facts everyone should know about rehab treatment for alcohol and drugs dependency. In 1999, Dr David Best, myself and an ex-CEO of EATA met to initiate an easy-to-use reference document about addiction treatment, covering key issues and based on incontrovertible research.
GET FIGURES FROM PROBATION
Providence Projects claims that DTTO figures for the three years that it held the contract for Dorset (before the NTA stepped in) “clearly showed that our outcomes of success were over 60% – these were figures probation put together”.