NUMBERS AND TICKBOXES MUST NOT STRANGLE PUBLIC HEALTH
Following Addiction Today’s identification of only 2% of patients managing to access drug-free rehabs, Dr David Best diagnoses what is wrong with a treatment system in which maintenance prescribing is the driver rather than a supportive adjunct.
This is the Cover Story of Addiction Today, January 2009.
On 2 October 2008, the National Treatment Agency for Substance Misuse issued a standard statistical bulletin asserting that there had been 202,666 people engaged with structured drug-treatment services in 2007/2008, of whom 133,024 were retained in treatment on 31 March 2008. This equates to 65.6% of all those with contact in the past year, the same figure as the previous year.
It is reasonable to assume that most of this retained group were opiate users of whom the majority are retained through substitute prescribing. Compared to previous years, the numbers showing as being in treatment are up and 12-week retention is up, indicating the NTA is “on track” to meet its targets.
It also appears that the use of opioid substitution treatment as the cornerstone for this increase in treatment engagement and penetration is consistent with guidance from the National Institute for Clinical Excellent (Nice, January 2007) and with international evidence on treatment effectiveness (Prendergast 2002; Marsh 1998). Yet… debate persists in the UK.
The debate is not about whether methadone has a role to play, but about its role in a treatment system in which, it will be argued, the ease and convenience of substitute prescribing for all of the parties involved has strangled choice, starved the field of hope and created a depersonalised processing system which has made it harder for people seeking help to ‘come out the other end’.
OVERDEVELOPMENT, AND EROSION OF NATURAL SUPPORT
There is general recognition that recovery is a long-term process involving effective community integration and that short-term acute treatments are not enough. Yet as Bill White warns, “where professional institutions and services have been overdeveloped… they may inadvertently erode natural support structures and, in doing so, inflict long-term injury on the community… treatment is best thought of as an adjunct of the community rather than the community being viewed as an adjunct of treatment” (White, in press, p7).
White and Kurtz (2006) have previously emphasised the importance of “multiple pathways and styles of long-term recovery” as central to the process of sustainable and meaningful recovery. The danger of a system driven by targets around numbers in treatment and retention is that this choice has been subordinated to a standardised package of prescribing and chatting (see evidence base below) which is suboptimal and denies meaningful choice to clients.
In spite of generally positive findings in outcome studies, there have long been reservations about maintenance prescribing, particularly for methadone. In 1985, Hunt and colleagues’ article It takes your heart was an ethnographic study that characterised the loss of status and credibility when drug users entered the world of “methadone, wine and welfare”.
This stigma of maintenance as failure is seen both as a barrier to entering treatment and as contributing to the learned helplessness of clients who embrace a treatment without end.
There might also be a more direct psychological manifestation of the deleterious long-term impact of opioid maintenance prescribing in recent work on neuropsychological functioning. Earlier work had suggested there was little effect of methadone maintenance on task performance, such as driving – but more recent work with methadone-maintenance clients showed impaired performance on cognitive speed, short-term working memory and decision making.
Mintzer, Copersino and Stitzer (2005) found that methadone maintenance was linked with additional impairment over and above that associated with long-term opiate use, and that maintenance is linked with deficits on tests of cognitive speed, short-term working memory and decision making (Mintzer and Stitzer 2002).
More worrying for those who argue for the indefinite prescribing, is what Davis et al (2002) found in a study of neuropsychological functioning in drug-free treatment programmes, methadone maintained clients and controls. They discovered that both drug-using populations performed worse than controls – and that cognitive performance in former opioid users was significantly better than in those on methadone maintenance.
In other words, the longer people are on maintenance, the more difficult it can be for them to muster the psychological resources to enable effective change.
“The ease and convenience of substitute prescribing for all of the parties involved has strangled choice, starved the field of hope and created a depersonalised processing system which has made it harder for people seeking help to come out the other end”
Part of the reason for this might be related to the lifestyle associated with long-term prescribing, particularly among the most vulnerable maintenance clients.
In the US, Hunt and colleagues (1986) found that not only were one in six methadone clients drinking heavily but that they spent much of their time on the streets and engaged in other forms of substance use.
In my own research in a London maintenance clinic (Best et al 1999), we found a third of maintenance clients drinking at excessive levels, and that this drinking behaviour was linked with other high-risk activities, such as regular nonprescribed benzodiazepine use and greater risk of overdose.
Weiss et al (1988) reported that problem drinking is linked to poorer treatment outcomes in methadone patients.
So there is an evidence base that, whatever the gains are for public health and safety, there is a group of methadone clients whose functioning deteriorates, who spend much of their day topping up their methadone with diverted prescription drugs and strong alcohol, and who are stigmatised by public and fellow street users alike.
In spite of the evidence of iatrogenic effects, the justification for the widespread use of maintenance is twofold. First, evidence suggests gains for the community in improved public health and public safety (reduced crime and disease); second comes reduced risk to individuals from overdose and mortality.
The former has been used to justify the development of maintenance prescribing in prisons – in spite of a recent paper (McMillan, Lapham and Lackey 2008) showing no benefits of jail-based continuation of methadone-maintenance treatment on subsequent recidivism.
"No one should be written off as deserving no more hope than merely to be kept out of jail and kept alive"
There is a strong evidence base showing the benefits of treatment engagement on reduced mortality (eg, Warner-Smith et al 2002). But the much-lauded increases in drug treatment in England have actually been associated with increased drug mortality in the most recent year. The Office of National Statistics (August 2008) showed that there were 1,914 male deaths related to drug poisoning in England and Wales in 2007, the highest recorded number since 2002. This compares with 1,782 deaths in 2006, representing a rise of 7% in the latest figures.
maintenance lobby’s effect on clients, workers and the public’s faith in addiction treatment
“As with treatments for these other chronic medical conditions [hypertension, diabetes, asthma], there is no cure for addiction” stated O’Brien and McLellan (1996). The recognition that addiction is a ‘“chronic, relapsing condition” has become both a mantra and a justification in medical-professional treatment services. It has been the basis of turning maintenance treatment into a treatment that is assumed to be lifelong.
Not least because of the poor evidence base for detoxification (Simpson 1980; Mattick and Hall 1986) and medical-professional scepticism about rehabilitation and mutual aid (White 2008), it is assumed that the safest course of action is to get people onto a maintenance prescription and to keep them there: “this is what the evidence-base suggests”. We are caught in a trap.
Few clinicians want a prescription to be a life sentence. And, according to the NTA user satisfaction surveys (eg NTA 2007), it is not what most clients want from treatment. But, as a field we have failed to develop a convincing evidence base about when or how people can successfully leave maintenance prescriptions behind and move to abstinence and recovery, if that is their goal.
This is not a neutral scientific finding. This has an impact on both workers and clients engaged in ‘safety-first’, indefinite, maintenance prescribing. It generates a cycle of ennui and pessimism in treatment, with workers delivering suboptimal care in which the prescription dominates and the requisite psychosocial interventions limp along in limited time – about 10 minutes every two weeks in our study assessing what goes in structured treatment settings (Best et al, in press).
It remains to be tested empirically if this is a consequence of the target-driven system in England, where the requirement to up the numbers in treatment might affect the resources and time available to each individual client (Ashton 2008).
This is not a uniquely UK problem. In the Dutch system, often held up as a model of effective maintenance prescribing in a coherent harm reduction model, Loth and colleagues (2006) describe the deterioration of methadone treatment prescribing in the previous 15 years: “Nursing staff have had to restrict their activities to simply dispensing methadone and have not been able to develop any other interventions” (Loth et al 2006).
The described situation – “Deterioration in methadone provision is demonstrated by a range of phenomena: the large number of patients to be served per hour, high staff turnover, many incidents of aggression at the counters, and limited facilities” – will strike a chord with many workers and managers in UK services.
This has created an often-disenfranchised and demoralised workforce facing a population with complex needs which cannot be addressed in 90 minutes per month. So the most vulnerable and alienated clients are most likely to have recourse in the world of “methadone, wine and welfare”. The workers will not be motivated by seeing them move on to full recovery.
There is another significant concern with the UK system, given this limited model of maintenance delivery, which is related to net-widening. There is active recruitment of clients into treatment via hospital liaison and, particularly, the criminal-justice system through Dip drug intervention programmes – so many individuals who are not appropriate for maintenance treatment and who will be vulnerable to the social, psychological and lifestyle risks which can be associated with maintenance prescribing, are engaged in this process with no adequate exit routes.
Our finding that clients receive an average of 90 minutes’ worker contact per month, of which only about one quarter could be described as “structured and evidence-based interventions” would suggest that, whatever the potential benefits of maintenance treatment packages, the current delivery is suboptimal according to the evidence on treatment delivery (McLellan et al 1993, McLellan 2007).
In a second paper exploring activities in criminal-justice treatment sessions (Best et al, in press), one of our key conclusions was that this process of prescribing and maintenance -dominated treatment de-skills and de-motivates the drugs workers. This in turn reduces their efficacy and their capacity to engage and motivate their clients.
Why maintenance is not enough
The international evidence base is sufficiently robust and strong that there can be no question of throwing the baby out with the bath water – the point of this article is to make clear that not only is maintenance prescribing not sufficient for a treatment system, it also cannot be the standard or default form of treatment for opiate addicts, far less for the polydrug-using populations we typically see in UK drug services.
Our response to a chronic, relapsing condition must be to support clients to long-term recovery – with medication as only a supporting part of the process, not a proxy for adequate treatment.
To conclude on a note of hope, the recent focus on recovery and on community-driven pathways suggests for us that the resources for long-term recovery lie not in liquid handcuffs, prescription pads or in expert treatments, but instead in individual growth and community-driven
In criminology, the increased optimism generated by lifecourse models stems from research (Laub and Sampson 2004) following up youth offenders to the age of 70. By this time, few of those alive were still offending – the majority had grown out of crime, as they had grown out of problem alcohol and drug use. The catalysts that which enabled them to achieve this were life milestones : satisfactory jobs and satisfactory relationships, as well as changes in their self-identities and belief systems. For many, this did not happen until their late 30’s or early 40’s.
messages of hope
So take two messages of hope from this work…
First, recovery is possible, but it can take a long time, and it can take a different amount of time for different people.
Second, nobody should be written off. None of the risk factors in adolescence – being chaotic, having family problems, early onset, and the like – were shown by research to be predictive. So there is nobody who should be written off as deserving no more hope than merely to be kept out of jail and kept alive.
The risk with maintenance is that we prescribe users through windows of opportunities for change and that the long-term deleterious effects of maintenance treatments gradually reduces the resources the individual has for lasting recovery.
Our version of maintenance is too depersonalised and suboptimal for this to be ‘treatment as usual’. It is essential that we offer much more real choice if recovery is to be more than the preserve of those who would have recovered in any case.
Our danger is that we create a self-fulfilling prophecy where the chronicity derives from the intervention, not from anything intrinsic in the condition.