Rediscovering Recovery: A Revolution in UK Drug Treatment Policy Neil McKeganey Professor of Drug Misuse Research University of Glasgow

Tackling Drugs to Build a Better Britain First National Drug Strategy 1998 Four Pillars: Young People Communities Treatment Availability Aim of Treatment: To Enable People with Drug Problems to Overcome them and Live Healthy and Crime Free Lives

Actions Ensure access to treatment. Provide advice on avoiding problems. Support drug users to review and change their behaviour towards more positive lifestyles. Provide an integrated and efficient response to people with drug problems. Ensure the availability of substitute medication. Improve range and quality of treatment. Ensure through-care and after-care. Develop collaborative coherent and cost effective services.

Treatment Works Number of drug users in treatment increased from 118,500 in 2001 to 202,000 in Funding for drug treatment increased from around £390m a year in 2002 to £800m a year in Massive expansion in the prescribing of methadone to dependent drug users 970,900 prescriptions in England in the year 1995 rising to 1,812,500 in 2004.

Estimated number of methadone clients in Scotland in 2002, 2003 and 2004 Source: ISD Scotland 2005

A Revolution in Drug Treatment Policy: From Harm Reduction to Abstinence

Rediscovering the Importance of Abstinence as an Outcome of Treatment I want to be clear the primary objective of any treatment has to be abstinence. We want as many users as possible to be permanently drug free and a positive influence in their families and communities. (Secretary of State for Health 2008)

National Treatment Agency Annual Report In the year ahead all of us in the field face the challenge to focus our efforts on the outcomes of treatment to enable more addicts to become drug free. (National Treatment Agency 2008)

Drug Treatment in Scotland (2008) In the government’s review recovery should be made the explicit aim of services for problem drug users in Scotland. What do we mean by recovery? We mean a process through which an individual is enabled to move on from their problem drug use, towards a drug free life as an active and contributing member of society. (Scottish Government the Road to Recovery 2008)

2010 UK Drug Strategy Reducing Demand Restricting Supply and Building Recovery A fundamental difference between this strategy and those that have gone before is that instead of focussing primarily on reducing the harms caused by drug misuse our approach will be to go much further and offer every support for people to choose recovery as an achievable way out of dependency. (Theresa May: Home Secretary)

2010 UK Drug Strategy We will create a recovery system that focuses not only on getting people into treatment and meeting process driven targets but getting them into full recovery and off drugs and alcohol for good. It is only through this permanent change that individuals will cease offending stop harming themselves and their communities and successfully contribute to society. Our ultimate goal is to enable individuals to become free from their dependence; something we know is the aim of the vast majority of people entering treatment. Supporting people to live a drug free life is at the heart of our recovery ambition. For too many people currently on a substitute prescription what should be the first step on the journey to recovery risks ending there.

DRUG USERS ON THE ROAD TO RECOVERY

Reductions in Heroin Use in the Last Three Months Amongst Respondents Interviewed on all Four Occasions (N=668)

Reduction in Severity of Dependence Score among respondents interviewed on all 4 occasions (N=668)

Changes in Acquisitive Crime in Last Three Months among respondents interviewed on all 4 occasions (N=668)

Changes in Homelessness among respondents interviewed on all 4 occasions (N=668)

Changes in Paid Employment among respondents interviewed on all 4 occasions (N=668)

Changes in Unsafe Drinking among respondents interviewed on all 4 occasions (N=668)

Changes in Self Harming behaviours among respondents interviewed on all 4 occasions (N=668)

Changes in Needle Sharing among respondents interviewed on all 4 occasions (N=668)

Who Achieves Abstinence ( totally drug free for 90 days prior to their DORIS 4 interview?) 5.9% of females 9.0% of Males 4.9% of those recruited from prison 6.4% of those recruited from other community based services 24.7% of those recruited from residential rehab services

% Totally Drug Free for 90 Days Prior to DORIS 4 Interview

% Abstinence at DORIS 4 (with possible substitute prescribing)

Physicians Health Plan (Humphreys et al 2011) Of the 802 physicians seen for five year or longer 81% had no relapse and abstained from drugs and alcohol for the full length of monitoring. Of the 19% who had at least one positive drug test only 26% had a second positive test over the five year duration.

Hawaii Opportunity Probation with Enforcement 85% of HOPE probationers completed the programme. In a 12 month period 61% of the drug using offenders on probation had no positive drug tests and 20% had one positive drug test. 9% had two positive drug tests 5% had three and less than 5% had more than four positive urine tests.

South Dakota 24/7 Sobriety Project for those convicted of driving whilst intoxicated. Alcohol intake regularly monitored through transdermal alcohol bracelet. 78% of respondents fully abstained from alcohol

These Programmes Share Focus on abstinence Close monitoring through urine testing of patients Rewarding sobriety Swift sanctioning against drug or alcohol use.

So What is Wrong with Drug Treatment? Disagreement over the aims of treatment - is it abstinence or is it maintenance? Addicts who embrace an ultimate goal of abstinence should be assisted in every way possible but they must be advised with brutal frankness of the low prospect of success and the grim potentially fatal consequences of failure. (Dr Robert Newman 2005)

So What is Wrong with Drug Treatment and What are the Problems that Need Resolution? Problems over the number of drug users in treatment. There are estimated to be around 200,000 drug users in treatment within the UK at the present time. That number is simply too large for all individuals to be provided with high quality recovery oriented care and treatment.

So What is Wrong with Drug Treatment and What are the Problems that Need Resolution? The Failure to Provide Services that are Focused on Abstinence Over 70% of drug users in treatment are provided with methadone with very little focus on their becoming drug free. Less than 2% of drug users in treatment are provided with access to abstinence based residential rehabilitation services.

So What is Wrong with Drug Treatment and What are the Problems that Need Resolution? The Problem of Quality in the Staff Providing Treatment Only a minority of staff within drug treatment agencies have undergone university training

So What is Wrong with Drug Treatment and What are the Problems that Need Resolution? The Failure to Assess and Monitor Drug Abuse Treatment Services Public bodies do not routinely evaluate the effectiveness of drug and alcohol services. Less than one percent of total spend by NHS boards and councils on drug and alcohol services is used for research and evaluation purposes. (Audit Scotland 2008)

So What is Wrong with Drug Treatment and What are the Problems that Need Resolution? The Fear on the Part of Staff With Regard to Moving Patients Towards Abstinence. Patients started on opiate substitution treatment had a twofold to threefold higher risk of death in the first 14 and 28 days of treatment compared with the risk during the rest of their time on treatment. The risk of death increased eightfold to nine fold in the month immediately after the end of opiate substitution treatment. (Cornish et al 2010)

So What is Needed to Realize Policy Aim for Abstinence Focused Drug Treatment Reduction in the number of drug users in treatment. OR Tighter specification of the characteristics of those drug users who might be able to achieve abstinence and who might benefit from a recovery focused drug treatment services.

So What is Needed to Realize the Policy Aim of Abstinence Oriented Drug Treatment Services? Training to enable and encourage staff within drug treatment services to work with clients in an abstinence/recovery focused way. The provision of services that reduce the risk of overdose on the part of those drug users working within abstinence based treatment programmes (naltrexone)

So What is Needed to Realize the Policy Aim of Abstinence Oriented Drug Treatment Services? The capacity to monitor and independently evaluate the effectiveness of drug treatment services.