1. The end of addiction careers DR DAVID BEST UNIVERSITY OF BIRMINGHAM BIRMINGHAM DAT / NTA

2. Treatment WORKS! DARP TOPS DATOS NTORS DORIS TREATMENT INTENSITY ENHANCED SERVICES

3. What Do Eminent International Experts Tell Us? “Addiction is not self-curing. Left alone, addiction only gets worse, leading to total degradation, to prison, and ultimately to death” Robert Dupont Director of NIDA 1993

4. “A Chronic, Relapsing Condition” “As with treatments for these other chronic medical conditions [hypertension, diabetes, asthma], there is no cure for addiction” O’Brien and McLellan, The Lancet, 1996

5. People receive around 45 mins of contact time per fortnight or 18 hours per year … Best et al (submitted ) Therapeutic Activity % of clients ever discussed % discussed in last session Complementary therapies 10.5%3.2% Alcohol interventions 9.3%4.4% Harm reduction 68.3%29.4% Motivational enhancement 1.5%1.2% Relapse prevention 66.3%34.0% Other structured interventions 22.7%14.0% Care planning 78.8%21.2%

6. Numbers in treatment

7. 04/0505/0606/07 Completed and/or drug free11,28815,22118,851 As % of all discharges24.8%29.2%34.8% As % of all contacts7.0%8.4%9.6% Successfully completed or retained in treatment 120,700 (75%) 135,090 (76%) 156,854 (80%) Number of PDUs completing drug treatment as a proportion of discharges and completions

8. Cultural effects of this model Disillusioned and instrumental staff Low expectations of clients Low expectations by clients Stigmatisation of treatment – “Methadone, wine and welfare” Net widening without commensurate changes in modelling of treatment

9. What has gone wrong with structured day treatment TARGETS Quantity Over Quality Quantity Over Quality Methadone based treatment Methadone, wine & welfare Models of chronic, relapsing condition Instrumental working Morale collapse & contagion Working in a tap factory

10. A clash of objectives Public health and safety OR Individual wellbeing The subtle incompatibility of goals across the addictions career

11. No Jail/Daily Drug Use (Male Opioid Addicts in DARP) N=405; Simpson & Sells, 1990 3 Years

12. Drug Use Outcomes: Community Treatment

13. Drug Use Outcomes: Residential

14. End Of Careers Study Sample of 187 former addicts (alcohol, cocaine and heroin) currently working in the addictions field, from total group of 228 former users 70% male Mean age = 45 years 92% white Worked in the field for an average of 7 years

15. Completed Heroin Careers

16. What finally enabled participants to give up? Not at allA littleQuite a lot A lot Physical health problems19.6%42.4%15.2%22.8% Psychological health problems 23.4%18.1%22.3%36.2% Criminal justice30.4%26.1%19.6%23.9% Family pressures36.0%24.7%21.3%18.0% Work opportunities76.5%9.4% 4.7% Support from partner72.6%15.5%6.0% Help from friends37.9%28.7%14.9%18.4% Tired of lifestyle6.3%4.2%13.5%76.0%

17. What enabled people to maintain abstinence? Not at allA littleQuite a lotA lot Support from a partner45.2%20.0%12.9%21.9% Support from friends14.5%21.1%16.9%47.6% Moving away from drug using friends 16.1%5.0%18.0%60.9% Having a job31.2%17.8%18.5%32.5% Having reasonable accommodation 10.3%17.6%26.1%46.1% Religious or spiritual beliefs22.3%11.4%16.3%50.0%

18. Qualitative data 12-step played a prominent role in achieving abstinence and particularly in maintaining it However, it appears to have coincided with psychological and environmental changes Readiness, awareness and insight are the main features that differentiated final success from previous attempts Formal treatment appears to have played a relatively minor role, and can act as a barrier…

19. Follow-up work Sub-sample of 63 dependent drinkers: Started drinking daily at 21.3 years Age of self-reported dependence – 25.6 years Age of first quit attempt without treatment – 31.7 years (n=47) Age of first AA meeting – 33.4 years (n=53) Age of first treatment – 34.8 years (n=51) Age of last drink – 36.5 years

20. Reasons for stopping Psychological health26 (41.3%) Physical health27 (43.9%) Criminal justice13 (20.6%) Work reasons / opportunities7 (11.1%) Help from family and friends25 (39.7%) Tired of Lifestyle51 (81.0%)

21. Reasons for staying abstinent Support from friends32 (50.8%) Moving away from substance using friends 34 (54.0%) Having a job20 (31.7%) Having reasonable housing30 (47.6%) Religious or spiritual beliefs30 (47.6%) AA40 (63.5%)

22. So where is this work going? Third wave of survey data to be collected Focus on outcomes and aftercare for day programmes and community groups Development of a recovery network for policy and research purposes Develop new techniques for sampling

23. Why is this research important? Because no other researchers seem interested in asking these questions Because we base our evidence on in treatment populations and those who experience treatment’s ‘revolving door’ Because of an increasing commitment to treatment careers and completions Because of the salience of ISG clients in treatment services, failure is over-stated and the biological model dominates

24. Intensity/ Severity Time Are there windows with increased opportunity for recovery? Pre- dependence (Escalation) Harm min (MMT/BMT) Prolonged dependence/ learned helplessness Maturing out (De-escalation) PositiveNegative Still life optionsLow motivation Not imbedded in crimeStill pleasurable drug use Non-dependentSubstitution activities (CM?) PositiveNegative Higher motivationBurned bridges Tired of lifestylemultiple morbidity Amenable to changeFew life opportunities

25. Is there a window for recovery? …. And does it fit with a back door to the treatment services? Evidence biased in favour of maintenance but little done on routes out of addiction and on supporting long-term recovery Aftercare? Housing? Employment? Can treatment and mutual aid be reconciled effectively?

26. So why has treatment contributed so little to the process of recovery?

27. Failures of evidence Tier 4 Aftercare Community detoxification Complexity of treatment journeys Failures of joint working Leaving us with an evidence base predicated on the medical / biological with little knowledge of social factors that predict success

28. Conclusion Drug treatment has become a population management strategy Failure is salient and success is hidden Only recently is abstinence becoming an acceptable aim to clinicians Irrespective of intensity and severity, addiction is a career, not a chronic, relapsing condition The key is recovery journeys that emphasise routes to abstinence and mechanisms for maintaining it

30. The Outcomes Star

31. And finally …… Addiction careers are not predictable but this study suggests that we do not have to commit to the ‘chronic relapsing condition’ mantra It is crucial that this message is disseminated to users and to workers alike Treatment purgatory cannot be perceived as a desirable state of affairs We need the evidence to promote this through policy mechanisms