empowerment
MAKING CH
How can we improve the range of options available to bring more people into services , asks DDN
The options that exist for drug treatment surely influence a person ’ s choice on whether to enter treatment at all . Broadly speaking there ’ s the pharmacotherapy option , using one of two main drugs as opioid substitution therapy ( OST ) – methadone or buprenorphine or both at different times – and there ’ s psychosocial support . Both are vital components in the package of support that people may need at different times in their lives to help reduce or end illicit ‘ problem ’ drug use . But there ’ s an unhelpful polarity that exists between interventions targeting immediate abstinence , and substitution treatments promoting stabilisation and harm reduction .
The use of OST has for a long time been challenged politically and through mainstream media . This cultural opposition , despite a strong evidence base for harm reduction , suggests that politicians and the public are still not fully aware of the benefits of this treatment approach .
In 2010 the ( UK ) drug strategy made clear the government ’ s concern that ‘ for too many people currently on a substitute prescription , what should be the first step on the journey to recovery risks ending there ’ and that it wanted to ‘ ensure that all those on a substitute prescription engage in recovery activities ’. Two years earlier in 2008 , the Scottish Government published The Road to Recovery , stating ‘ Recovery is a process through which an individual is enabled to move on from their problem drug use towards a drugfree life and become an active and contributing member of society ’. Both strategies were essentially saying the same thing ; drug treatment MUST be about becoming illicit or problem drug free , with the ideal being abstinent from drugs / alcohol .
The UK drug treatment sector refocus was sharp , and the proactive involvement of abstinence-based fellowships , groups and programmes proliferated . The sector was rebranded to reflect this aspiration and the lexicon was changed . ‘ Recovery outcomes ’ replaced treatment retention goals , and recovery coaches and mentors were set to support the change . It brought about the showcasing of visible abstinence-based recovery in the community and let communities see that ‘ people can and do recover ’. Services became places for working towards ending illicit drug use and OST prescriptions , and exiting drug free in a timely fashion . The government ’ s drug strategies would also influence clinical management and pharmacotherapy protocols , as noted in Medications in Recovery : reorientating drug dependence treatment : ‘ The task was to provide guidance to clinicians and agencies so they can help individuals on opioid substitution treatment ( OST ) achieve their fullest personal recovery , improve support for long-term recovery , and avoid unplanned drift into open-ended maintenance prescribing ’.
But there ’ s a significant problem with this , believes Stephen Malloy , who as a trainer , consultant and volunteer board member of the International Network of People who use Drugs ( INPUD ), has an insight into the disparate interests of stakeholders .
‘ The current paradigm dictates that the individual ’ s choice is simple – to engage with treatment and progress towards becoming a drug-free and active member of society , or not to engage . There ’ s no “ half way ” option … if you ’ re not compliant then it ’ s quite likely you ’ ll be exited from the service .’
Considering that the person making the decision to enter treatment could be motivated by an acute crisis in their lives , it ’ s a tough commitment to make .
‘ Suppose you ’ re a 40-something heroin user and you ’ ve been in and out of treatment several times over the last 20 years ,’ he says , by way of example . ‘ Your health is failing and you ’ re experiencing withdrawals from a break in supply of heroin on the street and there ’ s lots of other difficult stuff going on in your life , so you present at a drug service looking for a script . Imagine saying , “ well I ’ m only looking for a script to keep things stable . I might continue to smoke cannabis , I might still have a drink now and again , and
I want a bit of flexibility in my prescribing , because I might use illicit heroin again ”.
‘ I ’ m quite sure that the prescriber would explain that this would be impossible because of the risks attached to using on top of a prescription , in addition to prescribing being tied to compliance with a recovery programme and drug testing . So instead of saying this – which may be a fairer representation of where you are at – you agree to engage with a programme that you may not be “ ready ” for .’
Malloy meets ‘ lots of people in this situation ’, who appear to engage effectively with treatment until the crisis has passed . ‘ Then it ’ s a question of what happens next . Signs of returning to illicit drug use , or noncompliance with any recovery programme activity will likely bring about challenge by the service . Continued noncompliance will see you detoxed and exited from the services .’
Saying whatever needs to be said to get treatment can completely undermine ‘ one of the key factors that is pivotal to progress ’ – the relationship with workers or care providers , he says . ‘ That relationship has to begin with honesty .’ And for it to be honest , the person must have choices that are viable .
Fundamentally , we still don ’ t know enough about what motivates an individual to access treatment , he says , and so drug-related deaths ( DRDs ) continue to rise , with many of these people not in touch with treatment services .
Scotland ’ s system of having a drugs death database offers insight through ‘ a kind of social autopsy ’, he explains . This shows whether the person was working , their economic circumstances and whether they had been in treatment and on OST . It also looks at whether they had been in hospital recently or in touch with a GP , ‘ and what you routinely see is that 70 per cent of the people who die were in touch with some form of service in the six months before their death ’ – maybe a GP , hospital , community psychiatric nurse , or mental health care worker . Figures from 2014 show that only around a third of people were prescribed ORT ( predominantly
12 | drinkanddrugsnews | February 2017 www . drinkanddrugsnews . com