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!
