It is important for commissioners
to consider how innovation can
play a role in continuing to
improve care, while balancing
budgets... understanding the
balance between innovation and
organisational change is key in
Exponential growth of the problem
Treatment approaches emerged in the 1970s. Prescribed methadone doses were
often challenged and inpatient treatment duration limited in response to increased
demand and financial pressures. Subsequent explosive growth of problem drug use
in the 1980s and 1990s led to a resurgence in ‘maintenance prescribing’ and
introduction of on-site dispensing facilities with supervised consumption. Treatment
availability and coverage were lower than they are today, locally governed, commonly
led by NHS specialists and funded to provide services in a relatively limited capacity.
Expansion in treatment
The National Treatment Agency was established in the 2000s with the aim of
addressing the increasing problem of heroin use by improving treatment availability
and reducing waiting times. More resources and organisational change gave rise to a
competitive provider market, while new models of care were designed with an
emphasis on performance management. Innovative thinking led to a step change in
successful outcomes for people with problematic opioid use.
Evolution: a shift in focus
Recently the incidence of new heroin use has reduced. The existing cohort of
approximately 150,000 people remains engaged with treatment services, with
potentially greater needs related to comorbidity. The treatment system and method
has evolved: policy has promoted focus on recovery-oriented and abstinence-based
approaches, and concurrent mental health disorders have received greater attention.
In parallel a step-down in resources has occurred in many locations, placing stronger
focus on the need to achieve efficiency and cost-effectiveness in providing services.
Paul Musgrave, senior manager,
public health and communities,
Cumbria County Council
More on commissioning at
While funding for treating opioid-related disorders is decreasing in many areas, there
has not been an equivalent change in working practices to compensate. At the same
time, drug-related deaths have been increasing in all four nations, linked to the
ageing population and also unexplained factors. In many cases, services are
essentially delivering less of the same, which is keeping the system ‘ticking over’.
Looking to the future, it is relevant to consider if services are achieving the impact
the population needs and deserves. And in parallel, how can we focus on innovation
to maintain continuing improvement in outcomes?
There are a number of areas of innovation: use of digital technologies to provide
psychological interventions, different forms of opioid agonist medications, and
options to better address comorbidities such as hepatitis C virus (HCV) infection. It is
important for commissioners to consider how innovation can play a role in
continuing to improve care, while balancing budgets. There is already evidence of a
new group of injectable opioid agonist therapies from various pharmaceutical
companies which, if approved for prescription in UK, may allow treatment to be
delivered with injections weekly or monthly.
Current spending with community pharmacies on medications, supervised
consumption and dispensing is substantial. There may be opportunity to restructure
services to allow direct supply of medications or on-site storage at clinics, allowing
resources to be redirected. Understanding the balance between innovation and
organisational change is key in this instance.
Evolving treatment options pose questions about the different ways in which
therapy is tailored to the needs of the individual. In some cases, medications for
opioid dependency are used chaotically as part of a wider cocktail of drugs; f