1. Medications and Recovery: Promoting a more recovery-orientated approach; balancing aspiration with caution Professor John Strang National Addiction Centre, London, UK

2. Declaration (personal & institutional) DH, NTA, Home Office, NACD, EMCDDA, WHO, UNODC, NIDA NHS provider (community & in-patient); also Phoenix House, Lifeline, Clouds House, KCA (Kent Council on Addictions) Reckitt-Benckiser, Schering-Plough, Genus-Britannia, Napp, Titan, Martindale, Catalent, Auralis, Lundbeck, Astra-Zeneca, Alkermes, UCB, Fidelity, Rusan, Mundipharma Europe, Lannacher, Lightlake & others UKDPC (UK Drug Policy Commission), SSA (Society for the Study of Addiction); and two Masters degrees (taught MSc and IPAS) Work also with several charities (and received support) including Action on Addiction, and also with J Paul Getty Charitable Trust (JPGT) and Pilgrim Trust Support from Reckitt Benkiser Australia for support for attending this event

4. England/UK: NICE publications NICE technology appraisals on methadone and buprenorphine (TA114) NICE clinical guideline: Drug misuse: psychosocial interventions (CG51) NICE technology appraisals on naltrexone (TA115) NICE clinical guideline: Drug misuse: opioid detoxification (CG52)

7. The national policy context 2010 drug strategy: Substitute prescribing continues to have a role to play in the treatment of heroin dependence, both in stabilising drug use and supporting detoxification. Medically-assisted recovery can, and does, happen.... However, for too many people currently on a substitute prescription, what should be the first step on the journey to recovery risks ending there. This must change.

8. Published July 2012

9. Acknowledging … Bill White & Tom McLellan (JSAT paper - Betty Ford Foundation initiative) UKDPC Recovery initiative English DH Medications in Recovery Report of the Recovery-Orientated Drug Treatment (RODT) Expert Group

10. William Whites particular contribution As William White has commented: How recovery is defined has consequences, and denying medically and socially stabilized methadone patients the status of recovery is a particularly stigmatizing consequence.

12. UK Drug Policy Commission (UKDPC) Recovery statement The process of recovery is characterised by voluntarily sustained control over substance use which maximises health and well-being and participation in the rights, roles and responsibilities of society.

13. RODT - Where we start from … Treatment retention is not recovery Abstinence is not recovery Medication-assisted recovery – different types of medication (and many more to come) The evidence-base of MMT/BMT maintenance; and the danger of complacency Recovery importantly is to do with positives Nurture aspirations – empower and enable individuals

14. RODT Interim Conclusions Intolerance of sub-standard interventions (the poor results of treatment are sometimes the results of poor treatment) Attention to evidence base (and invest in objective examination) Look for synergies across modalities (e.g. CM and medication adherence; maybe rehabs and maintenance or relapse stunters) Nurture achievable desired aspirations (self; family?; society?) Safety net planning and special services (to support stumbling; and to respond quickly to tripping up)

16. The groups final report – July 2012 Heroin is often silent, and particularly sticky OST is important part of high-quality treatment system that substantially improves health and wellbeing For the right patient at the right time, OST can be heath-conferring, recovery-enabling and life-saving Bad OST or wrongly-applied OST can do harm Leaving treatment might be important but treatment termination isnt recovery Degrees of recovery – realistic aspirations Some people recover fast, some slow – but all need recovery support Done right, OST is effective but it should be viewed as a platform for recovery Dont end it too early: premature OST termination is hazardous OST termination carries risks: clinicians and agencies have responsibilities – increased case monitoring, extra support, safety net planning and resources

17. Conclusion: challenges and concerns Institutional inertia, therapeutic complacency and the distracting effect of the pursuit of cheapness Nurture aspiration in time of austerity – challenge for individuals in treatment/rehab; and challenge for practitioners and agencies Be prepared – alert to realities of individual situation and hazards of different pathways The crucial importance of safety net planning to stabilise stumbling and capture during fall

18. Thank you

26. Our report describes how more can be achieved: the task is now to achieve this.

27. potential medication synergies of the future

28. Time-relevance of medications Pre-RehabDuring RehabImmediate post- Rehab period Long-term post-rehab

29. Types of medications Prevention of co- morbidity Replacement/ Substitution Agonist Relapse Prevention Treatment of complication s and consequences

30. Types of medications Prevention of co- morbidity Replacement/ Substitution Agonist Relapse Prevention Treatment of complication s and consequences Exists and familiar Exists but still being developed Possible and on the horizon

31. Types of medications Prevention of co- morbidity Replacement/ Substitution Agonist Relapse Prevention Treatment of complication s and consequences Exists and familiar Hep B VaccineMethadone Buprenorphine NRT;bupropion Oral naltrexoneHep C treatment Exists but still being developed Possible and on the horizon

32. Types of medications Prevention of co- morbidity Replacement/ Substitution Agonist Relapse Prevention Treatment of complication s and consequences Exists and familiar Hep B VaccineMethadone Buprenorphine NRT;bupropion Oral naltrexoneHep C treatment Exists but still being developed Buprenorphine implant; Tabex Naltrexone implant/inj Naltrexone oral PRN craving Take-home emergency naloxone Possible and on the horizon

33. Types of medications Prevention of co- morbidity Replacement/ Substitution Agonist Relapse Prevention Treatment of complication s and consequences Exists and familiar Hep B VaccineMethadone Buprenorphine NRT;bupropion Oral naltrexoneHep C treatment Exists but still being developed Buprenorphine implant; Tabex Naltrexone implant/inj Naltrexone oral PRN craving Take-home emergency naloxone Possible and on the horizon Hep C Vaccine HIV vaccine Anti-craving medication Cocaine vaccine Nicotine vaccine Heroin vaccine Anti-hepC progression