UK’S TREATMENT WAR ON DRUGS:
A LESSON IN UNINTENDED CONSEQUENCES AND PERVERSE OUTCOMES
Kathy Gyngell says policy makers can no longer avoid the question of whether universal access to low-contact harm-reduction services has generated more harms than it has solved, in an article published in The Journal of Global Drug Policy & Practice this week.
Gyngell's analysis of the unintended consequences and perverse outcomes of the UK's substitute 'treatment' war on drugs challenges the received wisdom that the coalition government, despite its drugs recovery agenda, appears to have bought into. This is that the National Treatment Agency and the last government did a good job in establishing universal access to this type of drug treatment – so NTA functions should pass to the new Public Health England to continue that good job.
Gyngell shows it didn't. She shows that the still-dominant treatment numbers 'efficacy /cost effectiveness' paradigm does not hold up in face of actual versus experimental outcomes.
This is something that the Coalition must address if its new drugs recovery strategy is to work. For achieving genuine 'recovery' for more people could depend on treating fewer people but far more intensively to get them sustainably dependency free. It certainly means the Coalition facing up to the gross past and current misspending of large sums of taxpayersâ€™ money on ineffectual 'mass' drugs so-called treatment. It means being ready to turn off this tap, to face out the Department of Healthâ€™s counterproductive overprescribing of methadone and insist on an incremental shift of the balance of investment to proven abstinence programmes (with abstinence meaning not a brief stop in use but all the benefits of long-term sustainable recovery in its classic meaning).
This, she argues, will prove a more ethical and cost-effective 'harm reduction' strategy. For, despite low drug worker/client contact, harm-reduction treatment services have not and do not come cheap.
Annual average client treatment costs for England work out at almost Â£4,000 per client per year - a huge mark-up from the basic methadone dispensing and prescribing cost of only Â£39million a year (Â£300 per client per year), while annual average 'Tier Three' prescribing and 'Tier Four' client costs have been officially calculated at Â£6,064. Two years of that could pay for for six months of intensive residential rehabilitation or 12 months of more structured abstinence daycare.
Gyngell's figures show the shameful return from an english treatment budget of some three quarters of a billion a year. It "bought", she says, 2,476,000 methadone prescriptions but only a paltry 9,392 inpatient detoxifications and 4,711 residential rehabilitation interventions.
Yet becoming drug free, as treatment outcomes research shows, is associated with access to residential rehabilitation programmes or the achievement of a period of abstinence. It is hardly surprising that only 8,112 people were discharged free of drug dependency – 4% of the treatment population – last year. With crimes associated with problematic drug users still on the up, this is hardly a satisfactory return on investment.
But what of the part that this massive and costly treatment intervention has played in the litany of rising harms associated with drug use?
Here Gyngell identifies a litany of harms. That methadone treatment expansion has proved riskier than anticipated seems clear, with drug misuse deaths up to 1,876 in 2009 and those involving methadone rocketing from 220 to 408, by 85% since 2005, constituting a quarter of all drugs poisoning deaths. Such a rise, she says, found in any population other than addicts as a result of, or relating to, the medical treatment they were receiving, would, in all likelihood, "be the subject of a major inquiry".
Other harm-reduction orthodoxies, she argues, can no longer go unchallenged. Reported HIV infection among injecting drug users has been rising for a decade – over a period of unprecedented investment in harm reduction drug treatment – with 90%+ of hepatitis C infection now acquired by injecting drug users. She also refers to research which showed that being on methadone prolonged the median duration of this cohort of addicts drug 'injecting' careers from 5 to 25 years. This particular cohort (of 794 addicts followed over a 30 year period) also had prolonged poor health and poor quality of life and suffered high rates of physical and mental illness.
While retention in treatment and the benefits of 'maintenance' are no longer shouted out from the Department of Health's rooftops, there is no escaping the facts unearthed by Andrew Griffiths MP: a quarter of the NTA's prescribing clients have been on state-sponsored methadone for more than four years and a half of them for more than two years. And, as Gyngell reminds us, there are still no guidelines for getting clients off methadone, onto reduction and abstinence treatment plans
For the national policy "'obsession" with opiates along with the tyranny of its 'evidence base' for substitution prescribing has distracted, she argues, from understanding addiction - the reality of cross addiction regardless of substance, the replacement of one psychoactive substance by another, as well as from the problems caused by cannabis and cocaine. Doubling cocaine use in 10 years has led, since 1998, to a 129.5% increase in cocaine deaths (a 151.7% increase where cocaine was the only drug mentioned), a 304% rise in poisoning by cocaine (from 188 cases to 760 in 2009/10), and a 132% rise in cocaine-related mental health disorders (her analysis of HES data reveals). Even more ignored is benzodiazepine dependency and associated deaths, also on the rise from 190 in 2005 to 261 in 2009, (including an increase of 13%, in just one year, from 2008).
The irony is that harm reduction, though driven by the principle of risk aversion, perversely brings its own - and new – risks and costs. Leakage of prescribed methadone onto the illicit market is one. Death is another. Continued street drug and alcohol dependency and the welfare dependency is the one most brushed under the carpet.
The overwhelming message of this analysis is that true cost of spurning abstinence-based rehab – be it day or residential – and perpetuating dependency has yet to be computed.
Previous cost-benefits and value-for-money calculations, Gyngell reveals, paid little attention to year-on-year welfare dependency costs They failed to recognise that most of the treatment population (79%), just like most of the problem drug-using population (81%), are unemployed and on benefits. Treatment as delivered has not improved clients' employability or capacity for employment. Claims made by problem drug users in 2006 for Job Seekers Allowance, Incapacity Benefit, Income Support, and Disability Allowance, calculated at today's prices, using median claims for each category, come to a mind boggling Â£1,141,224,400 (Â£1.14billion). Including the 10.6% administration cost that the government calculates for, this rises to Â£1,262,194,186 (Â£1.26billion). Housing benefits estimated for this population at Â£531,440,000 brings their total estimated welfare dependency bill to Â£1.79billion.
To the social and economic costs of not freeing people from dependency we must add the child and family work attributed to drug use that was estimated in 2007 to be Â£1.2billion. As Gyngell points out, there is no evidence that the introduction of harm-reduction treatment services reduced the numbers of children needing special care or has reduced the risks that parental drug dependency exposes them to.
Editor's note: detailed data collections on the status and needs of children of clients in treatment have yet to be introduced, despite this request made by the Hidden Harm enquiry in 2003. The social and economic cost repercussions of not getting parents to be drug free, sober and rehabilitated for future generations are are yet to be estimated.
Gyngell's conclusion is one for the Coalition to listen to. Policy makers must radically and urgently reassess an approach that now dates back to 1988 when the UK's Advisory Council on the Misuse of Drugs declared that HIV/AIDS was a bigger threat to the public than drug misuse, from which point needle exchange and methadone became the default national response to drug addiction. The subsequent routine disregard for evidence which shows abstinence to be the best predictor of a range of recovery outcomes is untenable. Ignoring it is not an option If the Coalition is genuinely committed to a recovery agenda.