“Recovery” and the New Politics

I am sure that like me, you have become fed up with all this “recovery” talk – everyone in the addiction world seems to have an opinion, soap boxes have never been so trammelled, poles have never been further apart, and no one is any the wiser. But in the middle of all this hot air we have had a new government, and some of the whispers emanating from the corridors of power is that they have a very good idea of what “recovery” means to them – and that is off methadone, and off benefits. There has been talk of time limited methadone, and “payment by results” (PBR) which by inference, means being paid for leveraging people out of treatment.

You can imagine the hysteria that sort of thinking creates – from patients who have got used to the idea of being “maintained” on methadone, from lobbyists and advocates who espouse the rights of people to be in treatment, and from the practitioners of harm reduction, who like me are old enough to remember all too clearly the carnage resulting from enforced reductions and punitive practices 15 – 20 years ago.

Well I am as much a pinko liberal harm reductionist as the next man, but I also like playing Devil’s Advocate, so try out this dear reader: within a caseload of patients on methadone, there is a substantial number who will undoubtedly be there for a very long time, and possibly indefinitely – maybe those with serious enduring mental health problems, learning difficulties etc, I am sure we can all think of many who will almost certainly remain safer, more stable and have a much more certain and secure quality of life on their OST. But I think that if we were really honest, we might also identify a number who might, perhaps if we had tried a bit harder and offered more, have gained their independence from methadone, doctors and treatment systems a lot earlier. Harm reduction is such a manifestly good and safe thing to do, that maybe it can become a bit too comfortable for both patient and treatment team alike – whilst we smugly congratulate ourselves on the harm which statistics show we must be doing, perhaps we overlook those with greater resources who might be able to use OST simply as a brief bridge out of addiction and into stable long term non-dependency. I am sure this is the case: maybe there aren’t many in this latter category – but even if it is a handful, then it is a handful who could have been spared years in treatment systems if we had tried that bit harder.

The new government may have its prejudices, but at least it is currently soliciting expert opinion and encouraging discussions before they pronounce on what they want from us – and my view is that if we are to win the argument that there is a place for long term maintenance OST, possibly for the majority, then we will have to deliver “results” by working harder to help a minority to exit treatment.

So if you were to look at your caseload and try to identify “the low hanging fruit” – those who are most likely to be able to achieve durable opiate abstinence, who would they be? Little work has been done on this, but I came across a fascinating paper by Hser et al. “Trajectories of Heroin Addiction - Growth Mixture Modelling Results Based on a 33-Year Follow-Up Study” Evaluation Review Volume 31 Number 6, December 2007 548-563 © 2007 Sage Publications. This is an American study and we must always be careful about comparing apples with pears – the treatment system is very different in the UK to the USA – but this is a remarkable paper if only because it follows nearly 500 heroin using patients over 33 years – so it carries a great deal of rigour, and I very much doubt if there will be anything comparable in the UK in the foreseeable future. The authors identify three distinct sub groups of patients – the great majority (59%) they describe as “stable high level heroin users”, who have consistently maintained regular heroin use since OST initiation. The next biggest group they call “late decelerators” (32%) who maintained a high level of heroin use for approximately 10 years of OST, but then the percentage of nonusers started to increase, and lastly the smallest group (9%) of “early quitters” - These participants decreased their use within 3 years of initial use and stopped using altogether in the subsequent 7 years – so even early quitters still spent a long time in treatment.

So what were the distinguishing characteristics of these “early quitters” I hear you clammer? well I expect your intuition will be born out: third most important characteristic was that they had high “social capital” ie. they had jobs, supportive families and so forth. Second most important was that they started heroin use later than the other two groups, and you might surmise that good parenting helped to “protect” them from heroin exposure too soon. So what was the most powerful predictor of early quitting? Um, well, it was that this group was predominantly white – the other two being predominantly Hispanic or black – this was the USA after all!

And the BMJ goes One Better!

July 17th issue has a front cover showing a cup of methadone bearing the slogan: "Drug Users and HIV: Treat Don't Punish. Well amen to that, and inside is an editorial asking for an evidence based drugs policy and an excellent article by Steve Rolles titled "An alternative to the war on drugs" - with arguments that many of you might be familiar with if you have followed Transform's activities over the years. There is also a sobering article on the HIV epidemic in Eastern Europe (where methadone prescribing is not available). So, you might think - why is the NTA considering time limited methadone prescribing in the UK? (read the Guardian article here)

I don’t think this discussion from the NTA proposes that we come full circle, to the situation 15 years ago of enforced abstinence and time limited treatment, with its good evidence of being bad practice with poor outcomes. MMT studies over the past 15 years show a gratifying reduction in deaths, crime, and BBV rates – which is excellent, and the NTA would manifestly not disagree with those numbers, nor NICE etc….what I think they are trying to say is what all of us, if we are honest, know – namely that methadone for all its wondrous powers of harm reduction, is just as powerful at motivation reduction – and many patients just drift on for ever in (correctly) non punitive treatment regimes, using a bit of heroin now and again, and leading what most would consider to be very commuted lives, and generally contributing less to society and themselves than they could. Yes of course this is as good a life as is probably possible for those with mental health problems, learning difficulties or whatever ….and yes, if people want to use drugs in a controlled and relatively low-harm way, then I would defend their right to do so…. But politicians and the public have the right to question the bias towards a treatment which seems to preserve inertia (at enormous cost to the Welfare State) rather than facilitate change. We have all got anecdotes of people who are apparently wearing suits, holding down clerical jobs with a Ford Mondeo in the garage and happy children whilst taking 150ml methadone daily, but we have been bloody awful in the past 15 years at collecting evidence of that: the pleural of anecdote is not evidence….and the consequence of our failure to get evidence for what we think, is the problem which now faces us.

The most powerful motivator for an addict to change is the harm that he/she encounters, and methadone nulls out much of that harm which is why we use it. The challenge is preserve external drivers to change, whilst reducing the harm – that is the Philosopher’s Stone of addiction treatment.

BJGP has an interesting issue!

I thought that might grab your attention! this month's issue has an interesting editorial by Gerry Stimson and others on illegal drug use in an ageing population which pin points many of the challenges we will be facing in the years to come (as doctors that is!). And there is a slightly dry statistical analysis over 8 years of Scottish GPs treating drug users....but showing (with concern but no surprise to me) that "the new GP contract may have decreased GP involvement in treating drug misusers". But the star piece goes to Jenny Keen's group whose paper on a targeted GP led programme to treat addicted sex workers, which at one year recorded 100% of the cohort still retained in treatment, only 33% still sex working, heroin use had fallen and quality of life was enhanced. This is great general practice addiction work, and I suspect that many are doing equally good work elsewhere but Jenny seems to be the only one of us who has the energy, commitment and academic robustness to write papers.

(No hyperlinks I'm afraid, the BJGP is subscription only)

NICE Alcohol guidance

...has at last been released, and is fairly uncontentious. I think that some of the sections will fill acute Trusts with foreboding, as there is a clear mandate for admission for formal detox in some cases - making the standard policy (in some hospitals) of bouncing drunks out of A&E more difficult to defend. You can read the guidance here.

Loads of Stuff

This month I am indebted to Dave Targett at Turning Point for making my June Blog entry a doddle- because they have trawled the internet and given me all this inspiration.

The National Audit Office (NAO), have completed an audit analysis of the (cost) effectiveness of the actual government drug strategy and the effectiveness of local implementation. An interesting read that isn’t the whitewash you might expect. Click here to see it.

And here is a meta analysis of motivational interviewing and other psychological interventions in substance misuse - a magnificent effort by the authors on 25 years of published evidence.

Interested in supervised injecting and want to know the international experience? aside from Vancouver, Australia too has had very positive outcomes for its service users - a report can be found by clicking here.

And what about personal budgets? we are starting to get used to these in social care, but a pilot is being run now which aims to see if this approach can be extended to those accessing addiction services - now that should sharpen our act up! Click here to read about it.

Glastonbury festival this week - hurrah!

Conference Marathon completed!

Your scribe has completed the Grand Slam and been to Glasgow for the RCGP conference, then Liverpool for IHRA and finally Bristol for the RCPsych Faculty of Addictions conferences - all were great fun and very different: the RCGP was as usual a great event for networking, meeting up with old friends and seeing how GP addiction services are progressing around the country; IHRA was a gigantic meeting in beautiful Liverpool - many hundreds of delegates from all over the world to examine international drugs policies on Harm Reduction, with a good deal of time devoted to discussing "Recovery" - incuding Prof McKeganey bravely standing in the lion's den to debate his ideas....and Bristol? well give the RCPsych Faculty conference a try folks - it is a most exciting forum for discussing science and theory.... I heard a fascinating presentation on designer drugs amongst many others....next year's is in Newcastle - details will follow as usual.

So here's a bunch of links you might like to look at:

Want a bit of fun, and to direct carers and service users for education around overdose? - then click here for "The OD Game" and test yourselves!

For a billion statistics on injecting drug harm and needle exchange etc click here for the IDU reference group.

The British Pain Society's Guide to Opioids for persistent pain is a "must-read" for your CPD - download it by clicking here before they start charging for it!

Stanton Peel, veteran addiction psychologist who is always great value for a speech because of his forthright views, has his own blog which is much more entertaining than mine - click here and you will be whisked over to it.

And finally SMART is a new mutual aid recovery program which is spreading fast and may appeal to some who have, rightly or wrongly, been put off by 12 Step groups - they have a great website, have a look by clicking here.

Not so Legal Highs

Well our government has once again put media hysteria before science and slapped a ban on mephedrone, miaow miaow, or whatever it is known as.... clearly they have been so impressed with the effect that criminalisation has had on the quantity and safety of consumption of other drugs that it just can't wait for the scientific evidence to deliberate one way or another. It may very well be that this drug is harmful, certainly I wouldn't want to be sticking plant food in my body - but all the evidence of past mistakes would suggest that the act of criminalisation will simply make it more attractive, put the profits up for the black market, and encourage even more dangerous substances to be sold masquerading as mephedrone, or indeed diluting it. ...

Not that I have any confidence that the other lot would have acted any differently.....

RCPsych Conference in Bristol

This year's RCPsych Faculty of Addiction conference is to be hosted in the South West, in Bristol on April 29 + 30, and is being organised by Alison Battersby of Plymouth. There is a really excellent programme you can see by clicking here, and Alison has asked me to emphasise that GPs with an interest in addiction work will be particulalrly welcome. Clearly Addiction Psychiatry contributes greatly to the theory, knowledge base, research as well as practice of addiction medicine, and if you have ever felt that you need something perhaps more academic and scientific than many of the other conferences, then this could be for you. You can also download the registration form by clicking here. This will be a great opportunity to network with our psychiatry colleagues locally, and share our ideas and experiences.

Anthrax!

The mini outbreak of anthrax amongst Glasgow injecting drug users has come south - there has been a confirmed case in London. We don't know how these infections have occurred: one can speculate, but it doesn't help much - the fact remains that injecting materials into your body that have no aseptic, regulated, pharmaceutical provenance has, and always will be, very dangerous. just as in clostridial infections we must be alert to abscesses: anything that is hot, spreading, and is associated with systemic upset should be sent to A&E as a matter of urgency, along with a phone call to the (often inexperienced) SHO, with your concerns about something he or she has probably never heard of.

David Nutt strikes back!

I am delighted to read that Professor Nutt is reconvening like minded experts into a new group, free of government bias, to deliver clear, authoritative and apolitical advice on the safety of drugs. You can read about it here. No doubt the upcoming General Election will have the parties competing for the "toughest" stance on drugs, whilst at the same time planning to disinvest from treatment - if any of my readers have the ear of their local MP, please give them this simple message: the harms that drug use cause health have far more to do with their legal status than the drug itself - and that education and treatment will be far more effective at reducing that harm if they are properly financed, and certainly far more effective than criminalisation.