Medications in recovery: Re-orientating drug dependence treatment

Medications in recovery: Re-orientating drug dependence treatmentThis document re-examines treatment methods and objectives that can help the recovery of those with addiction problems.

This is an important step in meeting the ambitions of the people who use our services and of the government’s Drug Strategy 2010.

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Recommendations

  1. Investment in drug treatment since 2001 has given more people access to long-term, high-quality treatment, which has substantially improved their health. The task of the Recovery Orientated Drug Treatment Expert Group has been to describe how to meet the ambition of the Drug Strategy 2010 to help more heroin users to recover and break free of dependence. Heroin users are the largest single group in treatment and use an especially tenacious, habit-forming drug in the most dangerous ways.
  2. Entering and staying in treatment, coming off opioid substitution treatment (OST) and exiting structured treatment are all important indicators of an individual’s recovery progress, but they do not in themselves constitute recovery. Coming off OST or exiting treatment prematurely can harm individuals, especially if it leads to relapse, which is also harmful to society. Recovery is a broader and more complex journey that incorporates overcoming dependence, reducing risk-taking behaviour and offending, improving health, functioning as a productive member of society and becoming personally fulfilled. These recovery outcomes are often mutually reinforcing.
  3. The ambition for more people to recover is legitimate, deliverable and overdue. Previous drug strategies focused on reducing crime and drug-related harm to public health, where the benefit to society accrued from people being retained in treatment programmes as much from completing them. However, this allowed a culture of commissioning and practice to develop that gave insufficient priority to an individual’s desire to overcome his or her drug or alcohol dependence.
  4. This has been particularly true for heroin users receiving OST, where the protective benefits have too often become an end in themselves rather than providing a safe platform from which users might progress towards further recovery.
  5. Overcoming drug or alcohol dependence is often difficult. Only half of established smokers in England are likely to make a long-term recovery from tobacco dependence. In the USA, up to half of the alcohol-dependent population can expect to recover over the long term. Heroin and other opiates have a far worse prognosis: long-term USA studies suggest that, over 30 years, half of dependent users will die, one fifth will recover and the remainder will continue to use opiates, albeit some at a lower level.
  6. The existence of an accessible, evidence-based, drug treatment system in every part of England gives us an excellent opportunity to improve on the past by using international, historical evidence as the floor for our ambition and not its ceiling.
  7. England has stopped drug-related deaths escalating and has lower rates of blood-bornevirus infections than most of our European and North American neighbours. Most people who enter treatment want to recover and break free of their drug dependence. We can help more to realise this ambition if we can ally safe, evidence- based recovery-orientated practice to the public health and wider social benefits we already accrue from treatment.
  8. According to the research, the international track record and clinical experience, not everyone who comes into treatment will overcome their dependence. We know from the same sources that it is not possible or ethical to predict which individuals will eventually overcome their dependence. This is why we are obliged to create a treatment system that makes every effort to provide the right package of support to maximise every individual’s chances of recovery.
  9. Fewer young people are now coming into treatment for dependence on the most damaging drugs such as heroin, but there is an ageing cohort of drug dependent and ex-dependent individuals who will experience an increase in morbidity and mortality as theydevelop multisystem diseases that need complex treatment. Primary and secondary care services will be needed to treat them.
  10. The Chair’s interim report in July 2011 (Strang, 2011) was well-received and with support from the NTA has already resulted in practice improvements. This final report of the expert group details our collective view of how we go about channelling the energy and commitment of service users, commissioners and practitioners to achieve world-class recovery outcomes.
  11. Well-delivered OST provides a platform of stability and safety that protects people and creates the time and space for them to move forward in their personal recovery journeys. OST has an important and legitimate place within recovery-orientated systems of care. The drug strategy is clear that medication-assisted recovery can and does happen. We need to ensure OST is the best platform it can be, but focus equally on the quality, range and purposeful management of the broader care and support it sits within.
  12. If we stick closely to the compelling evidence for effective OST, and the existing guidance based upon that evidence, we will deliver many of the improvements needed – but we can and should do more. A determined assessment of the shortfalls in provision, followed by remedial action, is a priority if OST is to fulfil its potential in supporting recovery.
  13. There is no justification for poor-quality treatment anywhere in the system. It is not acceptable to leave people on OST without actively supporting their recovery and regularly reviewing the benefits of their treatment (as well as checking, responding to, and stimulating their readiness for change). Nor is it acceptable to impose time-limits on their treatment that take no account of individual history, needs and circumstances, or the benefits of continued treatment. Treatment must be supportive and aspirational, realistic and protective.
  14. Some people have a level of personal and other resources (called ‘recovery capital’) that enables them to stabilise and leave treatment more quickly than others. Many others have long-term problems and complex needs, meaning their recovery may take much longer and they require help to build their recovery capital. Treatment given over this timescale must maintain its recovery orientation.
  15. Arbitrarily or prematurely curtailing an individual’s OST will not help them sustain their recovery and is not in the interests of the wider community either. It risks losing any advances because it is externally imposed and so has no meaning – the individual does not own the decision. This would likely lead to an increase in blood- borne virus rates, drug-related deaths and crime. However, clear and ambitious goals, with timescales for action, are key components of effective individualised treatment, especially when the individual collaborates in planning them. We strongly support continued reference and adherence to the existing NICE drug misuse guidance (reviewed and unchanged in 2010-11) and to the more practitioner-orientated 2007 Clinical Guidelines.
  16. The more ambitious approach outlined will sometimes lead to people following a potentially more hazardous path, with the risk of relapse (or at least occasional lapse) as they seek to disengage from the OST that has supported them. Individuals (and their families), clinicians and services need to understand this potential risk. They need to approach the change with careful planning and increased support, and include a ‘safety-net’ in case of relapse.
  17. OST will improve as a result of changes at a system, service and individual level. These include:
    1. treatment systems and services having a clear and coherent vision and framework for recovery that are visible to people in treatment, owned by all staff and maintained by strong leadership
    2. purposeful treatment interventions that are properly assessed, planned, measured, reviewed and adapted
    3. ‘phased and layered’ interventions that reflect the different needs of people at different times
    4. treatment that creates the therapeutic conditions and optimism in which people, and especially those with few internal and external resources, can meet the challenge of initiating and maintaining change
    5. OST programmes that optimise the medication according to the evidence and guidance
    6. measuring recovery by assessing and tracking improvements in severity, complexity and recovery capital, then using this information to tailor interventions and support that boost an individual’s chances of recovering and improve his or her progress towards that goal
    7. treatment services that are not expected to deliver recovery on their own but areintegrated with, and benefit from, otherservices such as mutual aid, employmentsupport and housing
    8. treatment that works alongside peers and families to give people direct access to, or signposts and facilitated support to, opportunities to reduce and stop their drug use, improve their physical and mental health, engage with others in recovery, improve relationships (including with their children), find meaningful work, build key life skills, and secure housing.