Home Affairs Committee - Drugs: Breaking the CycleWritten evidence submitted by The Addiction Recovery Foundation & The Concordat of Rehab/Recovery providers (DP 137)

The Home Affairs Select has three domains for its enquiry into drugs policy:

1.A comprehensive review of drugs policy.

2.An examination of the effectiveness of the Government’s 2010 drug strategy.

3.The UK’s contribution to global efforts to reduce supply and demand of illicit drugs.

A Comprehensive Review of Drug Policy

The past 30 years has seen significant changes in UK drugs policy with, until recently, an entrenched emphasis on reducing the harm from drugs which had the unintended impact of keeping people sick for longer than necessary (treat symptoms not causes).

Harm-reduction dominance in the UK grew in the 1980s in response to a “heroin epidemic” and the discovery that one of the routes for HIV infection (and other blood-borne viruses) is via the sharing of needles to intravenously consume this drug. In response, needle-exchange programmes became widespread in an effort to reduce the likelihood of needle sharing (and an expectation of returned needles being safely disposed of). There is doubt as how effective this has been.1

Additionally, in efforts to reduce harms associated with drug-related crime, prescribed “substitute drugs” (methadone, buprenorphine, subutex etc) became so widespread as to be considered by commentators as the UK’s default treatment for heroin addiction.2

In turn, this type of “intervention” fuelled the misconception—against evidence to the contrary—that addiction is a “chronically relapsing disease” requiring long-term medication. It is a concern that considerable “support” for the medicalisation of addiction is generated by pharmaceutical opinion leaders with financial interests in the widespread use of medication.3 This is underscored by psychiatrists in the addiction field becoming more vocal in raising concerns about the research base for medicalised intervention, demonstrated by Dr James Bell of SLAM in his presentation at the 2011 Royal College of Psychiatrists’ annual addiction conference “Should recent evidence change your practice? The limits of evidence-based medicine?”4

Since 2001, illicit drug use treatment in England has been overseen by the National Treatment Agency for Substance Misuse. It has had responsibility for overseeing implementation and monitoring of the treatment side of national drug strategy. Under its regime, the focus of treatment in England has mainly been targeted on heroin and crack cocaine users (known as “PDUs”, problem drug users) and only on the problems of specific drugs rather than a holistic approach to tackling the causes of addiction (ie, a person can receive an intervention for a heroin problem but continue to use cannabis or alcohol, which enables cross-addiction rather than giving a route into drug-free recovery). The emphasis has been to keep people “gripped” in mainly-pharmaceutical treatment, sometimes for decades, with little strategy in relation to moving people toward living a drug-free life and reaching their full potential.

Over this time, the amount of public money spent on funding abstinence-based (ie residential, quasi residential and daycare) rehabilitation treatment has diminished in correlation to an increase in publicly-financed harm-reduction initiatives. Harm reduction is even called treatment, replacing it rather than complementing it. Highlighted in the NTA’s own figures is that less than 2% of the drug treatment-seeking population has access to residential drug treatment. It is estimated that about 66% of the UK’s £1.1 billion drug policy budget is spent on harm-reduction intervention.

This situation presents huge inequalities in treatment provision, depending on a person’s ability to pay. If a person requires residential treatment and has access to private finance, they can enter their chosen treatment in days. However, if a person requires statutory funding, they are expected to undergo a protracted process involving community treatment, and review at a funding panel in order to assess potential outcome.5

An Examination of the Effectiveness of the Government’s 2010 Drug Strategy

The Coalition’s first drug strategy was published in December 2010. It is probably too soon to make a thorough assessment of effectiveness. However, we wish to note some areas of concern.

Of particular note is the lack of a clear definition of “recovery”. There is confusion across the drug-treatment sector about what recovery is; and without a central definition, this confusion will grow. Already we are witnessing treatment organisations “rebranding” their historical services as “recovery” but without changing their practice to align with a recovery-oriented approach. Additionally, without a clear definition of recovery, it will be impossible to measure any publicly-funded intervention for outcomes/effectiveness. There are useful definitions of recovery from the US and Scotland which could be effective in England including “Recovery from substance dependence is a voluntarily maintained lifestyle characterised by sobriety, personal health and citizenship” and “Recovery is a process through which an individual is enabled to move-on from their problem drug use towards a drug-free life and become an active and contributing member of society”.6

We were delighted that the 2010 drug strategy indicated a much-needed change in direction for drug treatment in the England. But it is puzzling that the architects of the earlier system are now charged with implementing and delivering the changes, without workforce training, and that those with a track record of success in this area seem to be ignored (eg, in design of the Payment by Results pilots). Of major concern is the lack of consultation and joint working at local level between those tasked with purchasing and commissioning “recovery” services and those with a long history of providing such. It appears that the ‘old guard’ continue to confer only with “preferred providers” (ie, those who had provided the services which the 2010 drug strategy seeks to change).7

We have now established the Concordat Watchdog to provide an opportunity for anyone with evidence of non-compliance with government procurement requirements (including unfair competitive advantage, tendering or bias) to raise their concerns and thus improve local provision of recovery-focused services.8

While we are pleased to see the recent widespread mobilisation of “Recovery Champions”, we are concerned that a great many appear to be current “service users”—ie, people still in treatment rather than those who have completed treatment and have become a “person in recovery”; this can be linked to the absence of a definition of recovery. Additionally, with few exceptions, we are unable to identify what type of support Recovery Champions receive in undertaking this challenging role and whether there is widespread understanding that recovery advocacy (ie, being an inspiring face and voice of recovery) is not the same as recovery support (ie, having someone to talk to, personal growth, wellbeing etc). We would like to see this aspect of the 2010 drug strategy examined closely.

Work is currently being undertaken with the Concordat, the Recovery Partnership and the NTA so that all stakeholders—providers, commissioners, NDTMS data gatherers, officials and policitians—understand the same meaning from the same words and phrases in the National Drug Treatment Monitoring System and resultant reports. Only in this way can accurate outcome figures be extrapolated, and the sources which yielded them be identified, so that we will know what works and what does not, to guide investment. This will avoid necessity of translations such as
www.addictiontoday.org/addictiontoday/2009/10/the-dodgy-dossier-of-nontreatment-1.html and
www.addictiontoday.org/addictiontoday/2009/10/the-dodgy-dossier-of-nontreatment-1.html.

The UK’s Contribution Global Efforts to Reduce the Supply and Demand of Illicit Drugs

We would like to emphasise that one of the greatest contributions the UK can offer to this effort is to reduce the demand for drugs, which in turn will organically reduce the supply.

We require a shift away from “education” about drug use toward a stronger public health message of prevention.9 We must discontinue the UK culture of “accepting” drug use as “normal”—a change in culture will reduce demand.

Additionally, we should apply Lessons from Prevention Research and Preventing Drug Abuse among children and adolescents a research-based guide:10

Prevention programmes must enhance protective factors and reverse/reduce risk factors (Hawkins et al 2002).

They should address all forms of drug abuse, alone or in combination, including underage use of legal drugs (eg tobacco and alcohol); use of illegal drugs; and inappropriate use of ; legal substances, prescription medications, over-the-counter drugs (Johnston et al 2002).

They should address the type of drug abuse problem in the local community, target modifiable risk factors, and strengthen identified protective factors (Hawkins et al 2002).

They should be tailored to address risks specific to population or audience characteristics, such as age, gender, and ethnicity, to improve programme effectiveness (Oetting, et al 1997).

Family-based prevention programmes should enhance family bonding and relationships and include parenting skills; practice in developing, discussing , and enforcing family policies on substance abuse; and training in drug education and information (Ashery et al 1998).

Prevention programmes can be designed to intervene as early as preschool to address risk factors for drug abuse, such as aggressive behaviour, poor social skills and academic difficulties (Webster-Stratton 1998; Webster-Stratton et al 2001).

Prevention programmes for elementary school children should target improving academic and social-emotional learning to address risk factors for drug abuse, such as early aggression, academic failure and school drop-out. Education should focus on the following skills (Conduct Problems Prevention Research Group 2002; lalongo et al 2001); self-control, emotional awareness, communication, social problem-solving and academic support, especially in reading.

Prevention programmes for post-elementary school students should increase academic and social competence with the following skills (Botvin et al 1995; Scheier et al 1999); study habits and academic support, communication, peer relationships, self-efficacy and assertiveness, drug resistance skills, reinforcement of anti-drug attitudes and strengthening of personal commitments against drug abuse between schools, can produce beneficial effects even among high-risk families and children. Such interventions do not single-out risk populations, thus reduce labelling and promote bonding to school and community (Bolvin et al 1995; Dishion et al 2002).

Community prevention programmes combining two or more effective programmes, such as family-based and school based programmes, can be more effective than a single one (Battistich et al 1997).

Community prevention programmes reaching populations in multiple settings—eg schools, clubs, faith-based organisations and the media—are most effective when they present consistent, community-wide messages in each setting (Chou et al 1998).

When communities adapt programmes to match their needs, community norms or differing cultural requirements, they should retain core elements of the original research-based intervention (Spoth et al 2002b), which include; structure (how the programme is adapted, implemented and evaluated).

Prevention programmes should be long-term with repeated interventions (booster programmes) to reinforce the original prevention goals. Research shows that the benefits from middle school prevention programmes diminish without follow-up programmes in later schooling (Scheier et al, 1999).

Prevention programmes should include teacher training on good classroom management practices, such as rewarding appropriate student behaviour. Such techniques help to foster students positive behaviour, achievement, academic motivation and school bonding (Ialongo et al 2001).

Prevention programmes are most effective when they employ interactive techniques, such as peer discussion groups and parent role-playing, that allow for active involvement in learning about drug abuse and reinforcing skills (Botvin et al, 1995).

Research shows that £1 invested in prevention, a saving of up to £10 in treatment for alcohol or other substance abuse can be seen (Aos et al 2001; Hawkins et al 1999; Pentz 1998; Spoth et al 2002a).

One of the most important things that we must do in order to reduce demand (and thus supply) is to increase access to good-quality addiction treatment and recovery support for people who require it—and in so doing, to break the intergenerational chain of addictive and maladaptive behaviours. There is a growing awareness that recovery is contagious across families and communities which in turn can change the local culture and reduce local demand.

Money and efforts have been spent in recent years to reduce stigma associated with drug use (which seems counterproductive to the Drug Strategy goals)—but little or no attention has been accorded to the stigma associated with being in recovery. People in recovery experience stigma at a time when they are trying to move on in their lives (ie, accessing college, work, housing etc). In order for communities to “catch” recovery, people must feel safe in providing a visible example of recovery without risk of repercussions. This requires a greater understanding and promotion of the differences between drug use and recovery. To help enable this, the Concordat Graduates were established: people who have ‘graduated’ drug free from rehabs and into recovery and are willing to work with those who have achieved abstinent recovery through other routes.11

1 See http://journals.lww.com/jaids/Fulltext/2006/11010/Multiperson_Use_of_Syringes_Among_Injection_Drug.12.aspx for an example of research.

2 See www.cps.org.uk/publications/reports/breaking-the-habit for a comprehensive review of methadone prescribing. Also see some of the associated problems with the way in which our current system delivers substitution at
www.harmreductionjournal.com/content/9/1/3/abstract.

3 See www.independent.co.uk/news/uk/home-news/drugs-policy-advisor-under-fire-over-links-to-pharmaceutical-company-6261736.html and
www.independent.co.uk/life-style/health-and-families/health-news/professor-who-wrote-coalition-health-policy-was-paid-by-drugs-firm-2325928.html for examples.

4 For details, please read www.addictiontoday.org/addictiontoday/2011/07/psychiatrists-to-understand-recovery.html

5 See www.addictiontoday.org/addictiontoday/2011/11/state-of-residential-treatment-england.html for the most recent analysis of this and the impact of disinvestment in residential treatment on the treatment sector.

6 For the most recent definition also see: www.samhsa.gov/newsroom/advisories/1112223420.aspx

7 Please see www.addictiontoday.org/addictiontoday/2011/03/real-rehab-revolution-how-drug-policy-will-fail.html for further discussion on this.

8 www.theconcordat.net

9 See www.addictiontoday.org/addictiontoday/2012/01/prevention-in-context.html

10 www.drugabuse.gov/prevention/index.html

11 See http://theconcordat.net/concordat-graduates

Prepared 8th December 2012