House of Commons - Drugs: Breaking the Cycle

Drugs: Breaking the Cycle - Home Affairs Committee Contents

4 Treatment

Current treatment options

85. There are three main types of treatment for drug dependency:

a) Social or peer support such as Narcotics Anonymous, some of which use the 12-step approach pioneered by Alcoholics Anonymous. The programme is designed to help individuals re-build their lives and make amends to those they have hurt in the course of their dependence.

b) Psychological therapies (also known as 'talking therapies'). These therapies can be carried out either whilst the individual remains within the community or in a residential rehabilitation setting. The main psychological therapy used is cognitive behavioural therapy (CBT) which helps the drug dependent person to identify and learn to cope with the triggers for their drug taking. CBT is designed to prepare the individual for stressful situations by helping them develop a coping strategy which does not rely on drugs. As well as individual therapy, couples and family therapy is also used in treating drug addiction.

c) Pharmacological therapy, also known as opioid substitution treatment (OST). This is only available for those addicted to opiates (usually heroin) and is a method of reducing use of illicit 'street' drugs and in most cases is also intended to reduce injecting. There are several different types of OST—diamorphine, which is discussed above, methadone, which is the most common type of OST used in the UK, and buprenorphine, which is the second most common type of OST used in the UK and the principal treatment in some other countries, e.g. France and Sweden.

86. The National Treatment Agency for substance misuse supports the use of all three types of treatment for drug addiction, stating that there is no single treatment which is appropriate for all individuals. Instead the National Treatment Agency funds a range of community, inpatient and residential rehabilitation services, with the majority of patients treated within the community. The National Institute for Health and Clinical Excellence (NICE) has concluded that community treatment is effective for all but the most complex cases. Although some people respond best to residential rehabilitation, there is no guarantee that this will be sustained when they return to their communities, so there needs to be an effective programme of community-based support to help people stay clean after getting off drugs through treatment.[104]

HOW DO WE DETERMINE THE MOST EFFECTIVE METHODS OF TREATING ADDICTS?

87. At the start of the inquiry, the Committee examined treatment options available to addicts. The majority of scientific studies on the effectiveness of treatment show that Opioid Substitute Therapy (OST) is the most cost-effective initial way of reducing the prevalence of injection of street-bought heroin. This reduces both the criminal justice costs associated with the acquisitive crime committed in order to buy heroin and the public health cost in treating diseases associated with injecting behaviour. Buprenorphine substitute prescribing also has high cost-effectiveness in these areas and potentially more generally to the extent that a greater proportion of its users may be able to sustain employment although there are less studies available as it is a more recently deployed drug. It is important to note, however, that there is a paucity of research about how effective some alternatives to OST are. Anecdotally, for example, residential abstinence-based rehabilitation can be highly effective for some patients but there have not been as many funded research studies of these forms of treatment as compared to drug based treatments. As a result of this it is difficult to draw firm conclusions on the comparative effectiveness of different treatment options on the basis of currently available evidence either in terms of long term outcomes for the patient or in terms of value for money. In addition, OST alone rarely leads to abstinence and so the National Treatment Agency uses it in conjunction with psychosocial therapy to treat individuals dependent upon drugs.

88. A number of written submissions had highlighted the importance of residential rehabilitation and emphasised that the number of residential rehabilitation places had fallen over the past few years. Many of those who have been through residential rehabilitation stated that they would not have been able to recover from their addiction had they not been able to access residential rehabilitation. However, the National Treatment Agency will only offer residential rehabilitation in the most complex cases, partly due to the lack of research into its effectiveness but mainly due to the cost and the fact that, until the Drugs Strategy 2010, national drugs policy firmly emphasised maintenance and harm reduction rather than offering patients, who want it, a route to recovery. According to the NTA

The average annual unit cost of community treatment for a heroin addict is about £2,000. The comparable annual figure for treatment that includes residential rehab is about £10,000. This includes time spent in community-based services as well as the cost of a 13-week rehab programme and the cost of inpatient detoxification beforehand.[105]

89. A recent article in The Lancet examined scientific reviews of various aspects of drug policy, starting the different policy areas involved in international drug strategies.[106]Evidence for the effectiveness of health and social services for established drug users

Effectiveness Amount of research support and cross-national testing Comments

Methadone or buprenorphine opioid substitution treatment(OST) maintenance Good evidence for reduced mortality, heroin use, other drug use, crime, HIV infection, and hepatitis Studies done in many countries, including Australia, China, France, Germany, Indonesia, Italy, Iran, Lithuania, Malaysia, Poland, Spain, Sweden, Switzerland, Thailand, Ukraine, UK, and USA Appropriate for opioid users only. Combination with psychosocial services enhances outcome. Cost-effectiveness is high relative to other treatment interventions. The evidence-base is slightly stronger for methadone. The buprenorphine evidence-base might change after release of a buprenorphine plus naloxone combination formulation

Slow-release oral morphine OST maintenance Few studies, but produces similar benefit to methadone OST Trial data mostly from Austria, plus exploratory studies from Australia In Austria, slow-release oral morphine OST is used as well as methadone OST. It might have value for patients for whom methadone OST is not beneficial

Heroin (diamorphine) OST maintenance Evidence of effectiveness in reducing or stopping use of street heroin in individuals who do not respond to oral OST Demonstration programmes and randomised clinical trials in Switzerland, the Netherlands, Germany, Canada, and the UK Appropriate for opioid users only. Randomised trials have consistently shown positive results with this population, but heroin OST is the most expensive form of OST and is usually reserved for dependent users who have not responded to oral OST

Oral opioid antagonists (e.g., naltrexone[107]) maintenance Some evidence for reduced opioid use but compliance to treatment is a major limitation Few studies outside of the USA Targeted at opioid users, less than 20% of whom are willing to try this treatment. Oral naltrexone studies are of poor methodological quality and do not lend support to the potential effectiveness of the treatment

Needle exchange programme (NEP) Observational evidence that NEPs can reduce HIV infections and enable treatment engagement Most research done in Canada, the UK, Australia, and the USA Targeted at injecting drug users. Might prevent HIV infections but have no evidence of reducing Hepatitis C infections. NEPs have never been assessed by a randomised clinical trial

Psychosocial treatment Good evidence for reducing drug use, drug-related problems, and criminal activity Studies in most high-income countries and many low-income and middle-income countries, including India, Mexico, and Peru Appropriate for individuals using a range of drugs and administration routes. Can be combined with pharmaceutical treatment and delivered in outpatient and residential settings in group or individual formats

Behavioural family-based and couple-based treatment Several randomised trials show improved retention and benefit during treatment for heroin or cocaine addiction Research evidence is mostly from the USA Not widely applied in the USA, not tested in other cultures

Residential drug-free rehabilitation houses Very few randomised trials. Longer duration of residence associated with better outcome, although randomised trials show equal benefit from shorter programmes with follow-up or with similar day care Only moderate quantity of good-quality research evidence, despite long history of provision Extensively provided around the world in different forms, some based on programmatic therapeutic communities, some based on 12-step rehabilitation and recovery, and some based around religious communities

Peer self-help organisations Good evidence for the reduction of drug use and crime Evidence available from a range of countries as diverse as the USA, the UK, Iran, and China Highly cost effective. Probably the most widely available method of treatment globally

Brief interventions in general medical settings Good evidence for reducing drug use by at-risk drug users Evidence available from the UK, the USA, South Africa, India, Australia, and Brazil Evidence available for a variety of substances

Source: Strang et al, 'Drug policy and the public good: evidence for effective interventions, Lancet 379 pp 71-83, 2012

Role of residential rehab in the treatment system

90. Many of those who have been through residential rehabilitation stated that they would not have been able to recover from their addiction by another route. The lack of effective evaluation of residential rehabilitation was highlighted in a study by Professor John Strang and others which stated that there was only a "moderate quantity of good-quality research evidence, despite [a] long history of provision."[108] In contrast, evaluation on OST was extensive and worldwide.[109] Professor Strang told us that he was working with others to construct properly designed studies to produce a research evidence base for the future of residential rehabilitation and aftercare.[110] This disparity in the evidence base makes it difficult to directly compare different treatment options on some effectiveness criteria although, as stated earlier, it is already clear that although OST is an easier response for local drug services and comparatively cheap in the short term, it does not usually offer a route to abstinence.

91. Community treatment is supposed to comprise of OST and psychological therapy but that therapy will likely take place less often than it would in residential rehabilitation. In fact, in the NICE guidelines on OST, it is noted that the access to psychological therapy is "limited and variable around the UK"[111] and that OST "should ideally include psychosocial care, but that methadone and buprenorphine should be provided even when psychosocial care is not available."[112] The effect of these guidelines have been that local drug services were able to put heroin addicts on OST alone without any attempt to assess and treat the issues that lead to their dependence and with no attempt to support those addicts to come off OST. We took evidence from Wendy Dawson who runs a residential rehabilitation facility in Oxfordshire and has worked in a number of drugs and alcohol treatment services over the last 30 years. She told us that:

The problem was that we did not script people with an exit strategy; we just continued to script people. It is not unusual for us at the Ley Community to receive a referral from somebody who has been on methadone for over five years and has never been offered the opportunity of residential rehab.[113]

A number of witnesses commented on this problem of local drug services 'parking' addicts on OST and not having alternative treatment options in place for those patients who would clearly benefit. Chip Somers, Chief Executive of Focus 12 Rehabilitation Centre, is an ex-addict himself has been working with addiction and alcohol problems for over 26 years. While being clear that OST has an important role in drug treatment and that not everyone will be able to become drug free, his opinion was that maintaining someone on OST should not be seen as an ideal outcome:

Not everybody can achieve it [abstinence]. Not everybody can give up smoking. I think there is a really good purpose for methadone usage at a certain stage. But just to park people on methadone for four to seven years and more, it is criminal, really, just to keep people locked into that addiction because methadone usage is a dependency, you are totally dependent. It has a role but I think it gets overused and we just tend to use it as a response to everything, and we don't do enough to intervene…I don't think methadone usage is a good thing. I see very few people on methadone who are leading good, stable lives. Most of the people who are using methadone are also using other drugs on top. If I saw it producing good stability I would be much more in favour of it. I don't see that. What I do see is that people who are abstinent lead good, clean and decent lives, but obviously not everybody can achieve it.[114]

92. In July 2012, the National Treatment Agency also published a report on the role of residential rehab as part of the treatment system. As well as setting out the role of rehab, the NTA analysed its effectiveness and found that residential rehabilitation is often used, not as a stand-alone treatment, but rather as part of a network of services. The NTA found that three-quarters of residents came from community-based treatment services before accessing residential rehabilitation and the majority returned for further structured support afterwards.

For every ten people who go to rehab each year, three successfully overcome their dependency, one drops out, and six go on to further structured support in the community. Of those six, two overcome dependency with the help of a community provider, at least two are still in the system, and at least one drops out. Almost two-thirds of those who drop out from residential rehab do so in the first few weeks, suggesting that referring services and receiving facilities need to ensure people are better prepared before entering residential programmes and better supported during their stay.[115]

93. However, it is difficult to assess how this picture might differ following the production of a more rigorous evidence base about the variables affecting residential rehab and the outcomes achieved. In particular, it was concerning to hear from Wendy Dawson that some of the data might be being corrupted due to inappropriate referrals and an inadequate data collection system:

…a lot of residential rehabs have been sent inappropriate referrals; by that I mean people who are not medically able to sustain any form of intervention other than hospital. It is not unusual for clients to collapse on entry and be sent to hospital. That then skews the NDTMS [National Drug Treatment Monitoring System] figures, because it looks like it has been an unsuccessful intervention. There used to be a field in NDTMS that said "inappropriate referrals". That was recently removed, which is slightly disingenuous for residential rehab because we are providing a service and what we accept is the person that has been referred to us. Most residential rehabs have a very comprehensive assessment process that our assessment teams do very rigorously. That is not always reflective of the information that is captured in NDTMS, and it is not always reflective of the information that is supplied to the residential rehab provider.[116]

94. Different treatment regimes will work for different patients. It is clear that, for some people, residential rehabilitation is the most effective treatment, backed by proper aftercare in the community. Although it is expensive when compared to treatment entirely in the community, it is cost-effective when compared to the cost of ongoing drug addiction. While we welcome the Government's focus on recovery in the Drugs Strategy 2010, we have consistently been told that there is a shortage of provision, and in particular provision for specific groups such as teenagers. We recommend that the Government expand the provision of residential rehabilitation places. In addition, we recommend the Government review the guidance for referrals to residential rehabilitation so that inappropriate referrals are minimised and amend the National Drug Treatment Monitoring System form so that where incidents of inappropriate referral do occur they can be captured and an accurate picture of the effectiveness of residential rehabilitation as a treatment option can still be obtained.

95. The NTA also highlighted the disparity of effectiveness across the residential rehab sector. The research found that more than 60% of residents of the best providers go on to overcome dependence, while the poorest struggle to enable 20% or fewer to overcome addiction.[117] The NTA concluded that residential rehabilitation was "a vital and potent component of the drug and alcohol treatment system" and should continue to be so. It should not be seen as a separate treatment setting, or as an alternative to community treatment, but as one potential element of a successful recovery.[118]

96. Outcomes which range from 60% of patients overcoming their dependence to just 20% suggest that the quality of provision is very variable. We recommend that, in line with the publication of certain outcome statistics for National Health Service providers, publicly-funded residential rehabilitation providers should be required to publish detailed outcome statistics so that patients and clinicians can make better-informed choices of provider.

OST: METHADONE AND BUPRENORPHINE

97. Methadone was developed in the 1950s as a substitute for heroin. Buprenorphine was developed as a painkiller in the 1990s but it some became clear that it was a viable substitute treatment for heroin. It is sold under the trade name subutex and is the main OST available in France and Sweden. There are criticisms of both drugs. The RSA (Royal Society for the encouragement of Arts, Manufactures and Commerce) published interviews with recovering heroin users about their experiences and found that the negative consequences of methadone were widely recognised even by those who felt that the treatment was really helping them. In addition to the embarrassment of having to stand with other drug users in a methadone queue, key dislikes included the belief that methadone is very hard to come off, prescribed methadone use is simply another addiction, and methadone gets into 'your bones' and 'rots your teeth'. These concerns about methadone are repeated by Professor Nutt, who has comprehensively described the problems associated with methadone use in his work. He notes that buprenorphine was designed to address some of those problems[119] as it does not 'intoxicate' and 'sedate' like methadone does,[120] while still acting to block withdrawal symptoms associated with heroin use. However, buprenorphine may partly for this reason retain a somewhat lower proportion of previous heroin users in treatment than methadone. Its direct cost of prescription is also greater, although this is countered by the potentially greater ability of users in treatment to hold down employment..

98. Both drugs are used by the NHS when treating opiate addicts (although primarily used for heroin-dependent patients, OST can also be used for those who are dependent on other sorts of opiates, such as fentanyl, aprescription painkiller). In 2005, 16% of those on OST were using buprenorphine rather than methadone.[121] The National Treatment Agency does not collect data on which OST is prescribed, though Dr Gerada told us that her experience was of 90% of patients being on methadone, 1% on suboxone (a combination of buprenorphine and naloxon, a drug that blocks the effects of opioids) and around 9% buprenorphine alone.[122]

99. Professor Strang had undertaken an analysis as part of a wider previous study. He had identified that, after its introduction in 1999, the proportion of buprenorphine prescribing had steadily increased up to about 15% by 2005, but that it had remained steady at this proportion (about 15%) thereafter. He also noted that

The ratio between buprenorphine and methadone is approximately 1:6, but this varies considerably in different parts of the country, partly for reasons of clinical preference or judgement, I suspect, partly as a result of promotion of the pharmaceutical companies probably, and also because of legacy of concerns from earlier intravenous abuse of analgesic buprenorphine (e.g. especially across Scotland in the 1980s) so that it is much less likely to be prescribed as OST today.[123]

100. We make no comment on the relative merits of methadone and buprenorphine. It is for the individual prescriber to decide which drug is clinically indicated for each patient. However, we note that recent pharmacological advances in opioid substitution therapy mean that there are other options to patients being "parked" on methadone are notably treatment using buprenorphine which was less widespread when our predecessor committee published its report in 2002 and that it is possible that OST could in the future become a more effective route to abstinence than it has been in the past. Policy makers should understand the potential for more effective OST treatments and, rather than ignoring reports of the negative side effects of current OST drugs because they are available, familiar and cost-effective, should continue to keep sight of a greater emphasis on buprenorphine relative to methadone prescription to lead to better patient and societal outcomes.

Implementation of the Government's goal of recovery

101. The Government's 2010 drug strategy has recovery as one of its key aims. It states that recovery has three main principles— wellbeing, citizenship, and freedom from dependence before noting that recovery is an individual, person-centred journey, as opposed to an end state, which will mean different things to different people and that local services must commission a range of services at the local level to provide tailored packages of care and support. It also notes that medically-assisted recovery does happen and that there are many thousands of people in receipt of such prescriptions in our communities today who have jobs, positive family lives and are no longer taking illegal drugs or committing crime." It qualifies this however by stating that "for too many people currently on a substitute prescription, what should be the first step on the journey to recovery risks ending there."[124] The fact that each individual will require different support and different treatment options is further demonstrated by the RSA study which found that

This wide range and diversity of available support forms and sources is vital given that heroin users inevitably have their own particular histories, needs, preferences and aspirations. Some will feel that methadone or other substitute drugs help them, whereas others will not; some will enjoy going to groups or attending NA meetings, whereas others will not; and some will want to go into residential treatment, whereas others will not. Furthermore, their wants, needs and preferences will not be static. As a result, some individuals may not want a particular form of support at one point in time, but then desire it later.[125]

It is vital that the Government continue to offer a range of treatments in line with their goal of recovery.

102. The goal of recovery is a holistic (and potentially amorphous) one which does not focus solely on the physiological aspects of drug dependence but also on receiving assistance which may be needed with housing, education and employment. However, the stated goal of recovery has led to criticism from both those who believe it does not go far enough[126] and those who believe it promotes abstinence at the cost of harm reduction.[127]

103. A recent study which interviewed a number of recovering heroin addicts concluded that individuals with a heroin dependence demonstrated a very strong desire to progress their recovery journeys and that there was no evidence that individuals wanted to be given prescribed substitute drugs indefinitely. They generally disliked being on prescribed medications and wanted to detoxify from them, and from heroin, as quickly as possible. However, they noted that

our study participants' accounts clearly revealed that there is no quick or easy route out of heroin addiction. Indeed, trying to detoxify from prescribed opioids too quickly or trying to detoxify without rehabilitative support could easily lead to relapse. If an individual really wanted to recover, it seemed that they would need to work hard in treatment - both to understand themselves and their addiction and to foster the necessary life skills that would enable them to live without drugs.[128]

The study emphasised the importance of programmes other than treatment in order for recovery to be sustained "such as help with money management, education, training and employment."As well as the obvious motivation of helping them to rebuild their lives, another reason that such courses helped them was because by giving their day structure and keeping them busy it reduced cravings.This research supports the evidence we received from ex-addicts and practitioners in the field who were clear that the barrier was rarely an addict refusing treatment that would put them on a path to recovery but rather that they were unable to access such services. Wendy Dawson told us:

Just yesterday…we had a referral from a chap who had asked to go to residential rehab, had continued to ask to go to residential rehab, had been continually scripted with methadone, had asked to have his methadone reduced and in fact it was increased. He then decided to self-detoxify because he did not want to take methadone any more. He did, he became drug and alcohol free, asked to go to rehab, and he was told he was no longer a priority because he was drug and alcohol free. They are the kind of barriers that we face, because we had done our assessment, we were waiting for him, and he rang up and said, "I have been told I'm not priority." It took him to relapse for his commissioning panel to allow him-and I use that word "allow"-to come into rehab. Surely it should be about choice. The Community Care Act 2000 talked about service user choice. The Health and Social Care Act 2008 talks about service user choice. Where was the choice in treatment, whether that is a community-based treatment or a residential rehab?[129]

The successful implementation of the Government's recovery strategy requires the support of Local Authorities, the Department for Work and Pensions and the Department for Communities and Local Government. It will also require the support of the new Health and Wellbeing Boards which will have the responsibility of funding drugs treatment in the local area.

HEALTH AND WELLBEING BOARDS

104. One of the concerns raised with us about implementation of the Government's recovery agenda is that treatment funding will now be allocated by local Health and Wellbeing Boards. Because the funding of drugs and alcohol treatment is no longer ring-fenced, there are concerns that it could lose out to other local priorities.[130] Noting that the local public health budgets are twice the amount currently spent on drug and alcohol treatment services (around £1 billion a year), the ACMD supported the concerns expressed by others—including DrugScope; the Recovery Partnership; the UKDPC; the Royal College of Psychiatrists and provider agencies—about the risk of local disinvestment in drug treatment.[131]

In addition to the competing demands on funding, the removal of the drug treatment "ringfence" and the context of cuts in overall local authority funding, drug users (as highlighted by the UKDPC work on drug use and stigma), are a stigmatised population who can be perceived as "undeserving". The risk of disinvestment is underlined, for example, by the impact of the removal of the ring-fence for central government funding for the Supporting People programme—in the current financial year, some local authorities have reduced Supporting People funding by over 50%. Despite government funding for young people's drug and alcohol treatment being maintained in cash terms, there is evidence of significant reductions in service provision in some areas.[132]

They have also suggested that future trends in drug use, prevalence and incidence of drug-related morbidity levels and drug mortality data will need to be closely monitored to analyse the effects of differing types of treatment and the drug strategy as a whole.

105. The ACMD raised further concerns about the co-ordination between the Health and Wellbeing boards and drug treatment services located in prisons, saying that it was unclear how the NHS Commissioning Board (which will oversee prison based treatment) will work with community based services and the responsibilities of Health and Wellbeing Boards.[133]

106. Drug treatment in prisons is a point of critical intervention—if a drug-dependent offender is treated effectively then it greatly improves their chance of rehabilitation on release. Given that drug and alcohol dependence treatment in prisons has been so heavily criticised for the lack of co-ordination with treatment in the community, we are concerned that new structural changes may reverse the gradual improvement we have seen in treatment for drug-dependent offenders. We recommend the Government closely monitor the transition of treatment funding responsibilities to the Health and Wellbeing Boards and the NHS Commissioning Boards respectively.

107. There are also concerns that those in the local area will have a harm reduction background and therefore be less likely to advocate programmes aimed at recovery. One witness told us that many commissioners lacked the "ability to translate what they believe the national policy to be in their locality." He followed on by saying that "some comment on where commissioning fits is needed because that is where we translate the good practice and the high ideals into reality for an individual whose behaviour we are seeking to influence."[134]This is of particular concern to those who advocate residential rehabilitation which, as a more expensive treatment in the short term, could be considered to be less viable by the board.[135]

108. However, the Home Office have stated that the benefit of giving responsibility for funding to the Health and Wellbeing Boards is that they will be able to react to local needs in determining where budgets ought to be allocated. The "greater control of budgets locally to make decisions in response to local need, will enable increased flexibility. Service provision will be tailored at a local level, achieving efficiencies and delivering the best possible joint services in response to local need."[136]

109. The Government goal of recovery will require the co-ordination of several government departments: the Department of Health to ensure that effective treatment is being funded, the Department for Work and Pensions to support patients to re-enter the workforce and local authorities which must take responsibility for ensuring that they have appropriate accommodation. We believe that giving the Home Secretary and the Secretary of State for Health joint overall responsibility for coordinating drug policy (see paragraph 83) will help to improve the focus on the goal of recovery. We recommend that the Inter-Ministerial Group works with the Recovery Committee of the Advisory Council on the Misuse of Drugs to carry out an assessment of how the situation is working once the changes have been fully implemented, and to publish its findings by July 2013.

Payment by results

110. The Payment by results pilots are running in eight local areas: Bracknell Forest, Enfield, Lincolnshire, Oxfordshire, Stockport, Wakefield, West Kent and Wigan. The three stated key outcomes for recovery are:

free from drug(s) of dependence;

reduced offending: and,

health and wellbeing.

111. Several concerns have been raised about implementing a payment by results model within drugs treatment. The UKDPC told us that

The evidence suggests that where it works is where you have a single, very clear outcome, and you are quite clear about the interventions that will get you there, so that everybody is clear about what needs to be done, and about the outcome you are going to pay for. Unfortunately, recovery does not really tick those boxes. Recovery is recognised as a very complex and individual process. People start from different points. They have different resources themselves, and they may also have a different opinion of what recovery will mean to them. It is very hard to pay for recovery or to measure the recovery when you get to it.

They also raised concerns about the interim payments included in payment by results, which recognise that it will be a long time before some people achieve the abstinence outcome, as they suggest that such payments could skew the objectives of the scheme. By giving a high weight to the interim outcomes, it makes the long-term outcome less attractive. If the long term outcome is weighted more heavily then providers could decide that certain individuals are not worth treating.[137]

112. One of the concerns raised by witnesses was that organisations which have a payment by results structure may not wish to take on clients who are particularly complex or difficult. The Royal College of Psychologists told us that they were concerned that the payment by results systems "in their current form will fail to take account of the most vulnerable individuals, with the most severe and complex addictions, for whom the recovery journey will be most difficult."[138] This was supported by DrugScope who told us that payment by results may not be supportive of smaller voluntary and community sector providers who find it difficult to manage the cash flow and financial risks associated with outcome-based payments, and there are risks of "gaming" the system, for example, cherry picking clients most likely to achieve the desired outcomes.[139]

113. The fears regarding the marginalisation of smaller voluntary sector providers (which were voiced by several organisations) seem to have been borne out in the case of the pilot in West Kent. The Kenward Trust, a provider of drug and alcohol recovery services in Kent, told us

My understanding is that only two large national providers eventually put in a bid [for the model in West Kent], so the first point that I want to make is that in our experience, a payment by results model will exclude smaller voluntary sector providers that can provide innovative and quality services, and that will certainly have good local knowledge and good well-established relationships with all the variety of agencies that we know contribute to a successful outcome.[140]

The Trust also raised concerns that the payment by results model could result in a substantial bureaucracy involved in collecting payments with a danger of becoming target-driven, rather than outcome-focused. There was especial unease about the potential for such a system to change by relationships "between the recovery worker and the individual who is sat in front of them when they have a tariff attached to their head."[141] The concerns the Kenward Trust raised regarding services becoming target driven were echoed the Substance Misuse Management in General Practice who told us that

Payment by results (PbR) in primary care based drug treatment—this outcome measure is being piloted in several areas and whilst measurable positive outcomes are important, it risks oversimplifying a complex issue. There are many people who are cared for over long periods in primary care, who are severely affected either by their substance misuse, or who have turned to drugs and alcohol as a result of complex problems. A system that financially rewards services that may "cherry pick" those individuals they perceive as having more "recovery capital", compared to primary care that commit to seeing all for as long as necessary, is flawed.[142]

114. Payment by results potentially produces a very cost-effective system in which the taxpayer pays only for successful outcomes. However, past experience in other areas such as employment has shown that it is easy for the market to become dominated by a small number of large providers, leading to the marginalisation of smaller, innovative voluntary sector organisations. Another risk is that the most difficult to treat patients may be denied access to services. We recommend that the Government establish ways to create provider diversity to ensure that smaller providers and civil society are not excluded and that a wide range of services are available. This could be achieved by ring-fencing a certain proportion of expenditure for such providers. The model will also need to ensure that providers are rewarded appropriately for taking on the most difficult patients, so that those who are harder to help will not be denied services.

Prescription drugs

115. The issue of addiction to prescription drugs has increased dramatically in the past few decades. In North America, this increase has lead to a situation where non-medical use of prescription opiates is on a par with heroin use.[143] This trend is also evident in Australia and is thought to have occurred as a result of low levels of available heroin.[144] In January, the Centre for Disease Control called the increase in non-medical prescription drug use an epidemic, noting that it was the fastest growing drugs problem in the United States and that since 2003, more overdoses had involved opioid analgesics than heroin and cocaine combined.[145] In a North American context, the International Narcotics Control Board 2006 Annual Report observed that "the high and increasing level of abuse of prescription drugs by both adolescents and adults is a serious cause of concern". Prescription drugs are now the second most abused class of drugs in the USA after cannabis and have led to a rising number of deaths.[146]

116. Because of differences between the US and UK healthcare systems—such as the monitoring of GP prescribing—it may be less likely that that such wide scale addiction to opioid analgesic could occur in the UK. However, the National Treatment Agency found that prescription of opioid analgesics in the community increased very rapidly from 228.3 million items in 1991 to 1,384.6 million items in 2009.[147]

117. A cause of concern in the UK is dependence upon benzodiazepines, which during the 1970s were prescribed for between 10 and 20% of adults in the western world.[148] These are drugs which help alleviate anxiety and insomnia. Following a 1988 report on the potential side effects with a recommendation to exercise judgement when prescribing benzodiazepines, prescriptions began to decrease. The National Treatment Agency found that the prescriptions of hypnotic and anxiolytic medicines [a group of drugs, that have sedative, sleep-inducing, anti-anxiety, anticonvulsant, muscle relaxant and amnesic properties, of which benzodiazepines are one of several available on the NHS] decreased from 878.7 million items in 1991 to 550.4 million items in 2009.[149]

118. Despite this decrease, in May 2011, a joint review of the literature was published by researchers at the National Addictions Centre of Kings College London and the School of Social and Community Medicine, University of Bristol which confirmed the perception that benzodiazepine misuse, either intentional or unintentional, is relatively common, but could not definitively establish its prevalence or trends in prevalence.[150]

119. The Royal College of Psychiatrists told us that there is significant evidence of changing drug use both in the UK and internationally. Of particular concern is "the apparent rise in the use of club drugs, over-the-counter medications, abuse of prescription medications and internet sourcing."[151] However, Dr Gerada of the Royal College of GPs reassured us that

What we have had in this country over the last decade is a fantastic training initiative, run, I hesitate to say, through the RCGP, also the RC of Psych, to educate GPs about prescribing, about safe prescribing, about giving two week prescriptions and not whole month prescriptions. I will say that in terms of diverted drugs, patients getting addicted on drugs that started life with a prescription of mine is very unusual now. Ten years ago it was very usual.[152]

120. It is not possible to assess the scale of dependence upon prescription medicine within the UK as the data on prescription drug dependence is not collected in the same way that data on heroin dependence is. Instead the majority of those in treatment who report prescription drug dependence will usually have used them in conjunction with other, illicit, drugs.[153] However this data may not be representative given the historic focus of drug treatment on heroin and/or crack and the fact that support and treatment for people who develop problems in relation to prescription only medicine or over the counter medicine would be provided by GPs, many of whom do not report to the National Drug Treatment Monitoring Service.[154]

121. When we questioned the ACMD about the prevalence of dependence upon prescription medication, we were told that although the situation was much better than in America, they intended, "to do a review of prescription medicine diversion to recreational use. We will be doing that next year."[155]

122. Prescription drug dependence and the use of prescription drugs for non-medicinal purposes is widely and erroneously viewed as being less harmful and certainly more acceptable than drugs which are part of the classification system. Prescription drugs are becoming more widely available, through diversion of prescriptions and unregulated sales via the internet. This was not an issue which our predecessor committee looked at in 2002 but we are alarmed by the increase in availability of and addiction to prescription drugs. Having seen first-hand the scale and impact of prescription drug use in Florida, we recommend that the Government publish an action plan of how it intends to deal with this particular issue as part of the next version of the drug strategy to prevent the situation here in the UK deteriorating further.

123. It is unacceptable that no government agency can give us information on the prevalence of dependence on prescription drugs. We welcome the proposed review of prescription medicine diversion by the ACMD. The issue is one which has been highlighted as a growing problem and as the overall trends of drug use change, the Government must ensure that it has access to suitable treatment for dependence on all drugs rather than just focussing on a narrow sub-set. It is ultimately the responsibility of the medical profession to ensure that their prescribing decisions do not lead patients into drug dependency. However, the police and public should be aware of this deeply concerning trend, so they too can be vigilant in seeking to prevent it.

104 http://www.nta.nhs.uk/facts-faqs.aspx Back

105 National Treatment Agency , The role of residential rehab in an integrated treatment system (2012), p 11 Back

106 Strang et al, 'Drug policy and the public good: evidence for effective interventions', Lancet, vol 379 (2012), pp 71-83 Back

107 Naltrexone helps patients overcome opioid addiction by blocking the drugs' euphoric effects although it has little to no effect on cravings. Back

108 Strang et al , 'Drug policy and the public good: evidence for effective interventions', Lancet, vol 379( 9810, January 2012) Back

109 Ibid Back

110 Q163 Back

111 NICE, Methadone and Buprenorphine for the management of opioid dependence, (January 2007), p 23 Back

112 Ibid, p25 Back

113 Q122 Back

114 Q255 Back

115 National Treatment Agency, The role of residential rehab in an integrated treatment system (2012), p 3 Back