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The best treatment
system provides a
spectrum of
interventions for those
wishing to explore them.
While we live in a time of
‘austerity’ there has to
be sufficient funding in
the system... There isn’t
one size that fits all.
R
ecently, a post on social media considered the question of whether
talking therapies added any value to people who were committed
to opioid substitution treatment (OST) on a long-term basis.
National data shows the group of long-term, committed
recipients of OST is growing, month on month, across the country.
However it isn’t clear whether this is because of a personal desire for,
and commitment to, long-term OST, or because people have been stranded on repeat
prescriptions, with minimal contact from a practitioner – both conditions exist.
Certainly, the figures correspond with cohorts of individuals who have long
careers of substance use and are highly complex, and this brings into question
the ability of current treatment delivery to respond appropriately.
People may commit to long-term, or lifetime, treatment for a variety of
reasons, objective and subjective. There may be a clear clinical need in certain
cases; however, people also resist change and avoid challenge.
Pharmacological interventions are comparatively well researched and
evidenced, with the effects quite easy to predict and observe. Therapeutic doses
can also be achieved relatively quickly, enabling an individual’s physical
circumstances to be moderated effectively. But the effect of those doses may be
more than we envisaged in terms of affecting someone’s ability to interact, and
some researchers have linked methadone with significant cognitive impairment.
By comparison, talking therapies depend almost exclusively on the specific
relationship between the person and the practitioner to be effective – the
emotional context and connection, and a desire to respond or change dynamically.
NICE considers that few talking therapies have the evidence base to warrant
their use, particularly in this client group, preferring contingency management to
support people in OST. But if a person’s ability to reason is adversely affected by
opiate use, might this be the primary reason for the failure of talking therapies –
and should this be factored into decisions about treatment?
Other issues also come into play here. At what point has the impact on the
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individual been measured? How resistant is the person to talking? Do they
regularly miss appointments believing they won’t benefit from them? Do they
present on the autistic spectrum? Can they get their prescription and side-step
psychosocial altogether? All these questions are as relevant for the long-term
methadone patient as for the person just starting treatment, and make the
success of talking therapies difficult to qualify.
What could be of more importance is a person’s access to meaningful use of
time, whether to pursue hobbies, learning, look for volunteering or work
opportunities, or otherwise be diverted from their established courses of action
and interaction. There is a clear role here for mutual aid, residential rehabilitation
and therapeutic communities – yet aren’t these types of talking therapies?
Nicholas Christakis (Connected, Harper Press, 2009) speaks of changing
people’s outlooks and cultural position. He argues that individuals in a
concentrated network naturally exhibit its predominant emotions, actions and
cultural perspectives. To effect positive and sustainable change, exposure to
‘integrated’ networks, with a range of views and cultural stances is necessary.
Mutual aid and recovery communities are excellent gateways to such networks;
concepts such as time-banking and co-production enable individuals to explore
their aspirations, skills and knowledge. This is supported by the observations of
William L White in the United States.
Experience across the country has demonstrated the value of running such
programmes side by side, enthusing people to be involved in activities such as
equine therapy, working in the countryside, and time-banking with local
communities, at the same time as receiving OST.
Fundamental to this approach has been psychosocial support, providing an
opportunity to discuss issues, events and concerns in an encouraging, supporting
and enabling environment. Keyworkers and psychosocial practitioners can have a
crucial role to play in enabling individuals to experience and understand their
worth in such environments.
Any viable system must offer a range of interventions that present the most
options for pursuing a full life. If this isn’t also given to lifetime methadone patients,
including the option to stop OST, how can they make an informed judgement?
During my career as a commissioner, I’ve resisted the concept of tendering every
few years to find the ‘best response’, the ‘most economically advantageous tender’
and the ‘best provider’ for the task. Treatment provision is fundamentally different
to purchasing stationery and, while there’s a place for market testing, it can be
detrimental to long-term care and outcomes that celebrate the best in individuals.
Commissioning is an art form, working with people in treatment, families and
communities, providers and partners to ensure maximum opportunities are
identified, explored and delivered. It is about seeking solutions that are
sometimes the best, sometimes wrong, often pragmatic, but always looking to
offer individuals the chance to choose something that is right for