Transcript THE POLITICS OF TREATMENT - Selskab for misbrugspsykologi

The end of addiction careers
DR DAVID BEST
UNIVERSITY OF BIRMINGHAM
BIRMINGHAM DAT / NTA
Treatment WORKS!
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DARP
TOPS
DATOS
NTORS
DORIS
• TREATMENT INTENSITY
• ENHANCED SERVICES
What Do Eminent International Experts
Tell Us?
“Addiction is not self-curing. Left alone, addiction
only gets worse, leading to total degradation, to
prison, and ultimately to death”
Robert Dupont
Director of NIDA
1993
“A Chronic, Relapsing Condition”
“As with treatments for these other chronic medical
conditions [hypertension, diabetes, asthma], there
is no cure for addiction”
O’Brien and McLellan, The Lancet, 1996
People receive around 45 mins of contact time
per fortnight or 18 hours per year …
10.6
13.7
10.6
11.7
Case Management
Therapeutic Activity
Links to other services
Other
%
of clients
ever
discussed
%
discussed
in last
session
Complementary
therapies
10.5%
3.2%
Alcohol
interventions
9.3%
4.4%
Harm reduction
68.3%
29.4%
Motivational
enhancement
1.5%
1.2%
Relapse prevention
66.3%
34.0%
Other structured
interventions
22.7%
14.0%
Care planning
78.8%
21.2%
Therapeutic
Activity
Best et al (submitted )
Numbers in treatment
350,000
300,000
250,000
200,000
Numbers in treatment
Drug strategy target
Glasgow estimate
150,000
100,000
50,000
0
2003/04
2004/05
2005/06
2006/07
Number of PDUs completing drug treatment as a proportion of discharges
and completions
04/05
05/06
06/07
Completed and/or drug free
11,288
15,221
18,851
As % of all discharges
24.8%
29.2%
34.8%
As % of all contacts
7.0%
8.4%
9.6%
Successfully completed or
retained in treatment
120,700
(75%)
135,090
(76%)
156,854
(80%)
Cultural effects of this model
• Disillusioned and instrumental staff
• Low expectations of clients
• Low expectations by clients
• Stigmatisation of treatment –
“Methadone, wine and welfare”
Net widening without commensurate
changes in modelling of treatment
What has gone wrong with structured day
treatment
TARGETS
Morale
collapse &
contagion
Quantity
Over
Quality
Working in a
tap factory
Methadone,
wine &
welfare
Instrumental
working
Methadone
based
treatment
Models of chronic,
relapsing
condition
A clash of objectives
Public health and safety
OR
Individual wellbeing
The subtle incompatibility of goals across
the addictions career
No Jail/Daily Drug Use
(Male Opioid Addicts in DARP)
100
80
3 Years
60
40
51
53
Yr 2
Yr 3
59
57
Yr 6
Yr 12
40
20
0
Pre-Trt
Yr 1
% in Years After Treatment
N=405; Simpson & Sells, 1990
Drug Use Outcomes:
Community Treatment
100
Daily opiate use
80
Frequent opiate use
%
60
40
Occassional opiate use
Abstinent from illicit opiates
20
Abstinent from all drugs
0
Intake
6 months
Abstinent from all drugs
Occassional opiate use
Daily opiate use
1 Year
2 Years
Abstinent from illicit opiates
Frequent opiate use
Drug Use Outcomes: Residential
100
Daily opiate use
90
80
70
Frequent opiate use
%
60
Occassional opiate use
50
Abstinent from illicit opiates
40
30
Abstinent from all drugs
20
10
0
Intake
6 months
Abstinent from all drugs
Occassional opiate use
Daily opiate use
1 Year
2 Years
Abstinent from illicit opiates
Frequent opiate use
End Of Careers Study
• Sample of 187 former addicts (alcohol, cocaine
and heroin) currently working in the addictions
field, from total group of 228 former users
• 70% male
• Mean age = 45 years
• 92% white
• Worked in the field for an average of 7 years
Completed Heroin Careers
35
30
25
20
age
15
10
5
0
age of first
use
age of first
daily use
age of peak
use
age of last
use
What finally enabled participants to
give up?
Not at all
A little
Quite a
lot
A lot
Physical health problems
19.6%
42.4%
15.2%
22.8%
Psychological health
problems
23.4%
18.1%
22.3%
36.2%
Criminal justice
30.4%
26.1%
19.6%
23.9%
Family pressures
36.0%
24.7%
21.3%
18.0%
Work opportunities
76.5%
9.4%
9.4%
4.7%
Support from partner
72.6%
15.5%
6.0%
6.0%
Help from friends
37.9%
28.7%
14.9%
18.4%
Tired of lifestyle
6.3%
4.2%
13.5%
76.0%
What enabled people to maintain abstinence?
Not at all
A little
Quite a lot A lot
Support from a partner
45.2%
20.0%
12.9%
21.9%
Support from friends
14.5%
21.1%
16.9%
47.6%
Moving away from drug using
friends
16.1%
5.0%
18.0%
60.9%
Having a job
31.2%
17.8%
18.5%
32.5%
Having reasonable
accommodation
10.3%
17.6%
26.1%
46.1%
Religious or spiritual beliefs
22.3%
11.4%
16.3%
50.0%
Qualitative data
• 12-step played a prominent role in achieving
abstinence and particularly in maintaining it
• However, it appears to have coincided with
psychological and environmental changes
• Readiness, awareness and insight are the main
features that differentiated final success from
previous attempts
• Formal treatment appears to have played a
relatively minor role, and can act as a barrier…
Follow-up work
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Sub-sample of 63 dependent drinkers:
Started drinking daily at 21.3 years
Age of self-reported dependence – 25.6 years
Age of first quit attempt without treatment – 31.7
years (n=47)
• Age of first AA meeting – 33.4 years (n=53)
• Age of first treatment – 34.8 years (n=51)
• Age of last drink – 36.5 years
Reasons for stopping
Psychological health
26 (41.3%)
Physical health
27 (43.9%)
Criminal justice
13 (20.6%)
Work reasons / opportunities
7 (11.1%)
Help from family and friends
25 (39.7%)
Tired of Lifestyle
51 (81.0%)
Reasons for staying abstinent
Support from friends
32 (50.8%)
Moving away from substance using 34 (54.0%)
friends
Having a job
20 (31.7%)
Having reasonable housing
30 (47.6%)
Religious or spiritual beliefs
30 (47.6%)
AA
40 (63.5%)
So where is this work going?
• Third wave of survey data to be collected
• Focus on outcomes and aftercare for day
programmes and community groups
• Development of a recovery network for
policy and research purposes
• Develop new techniques for sampling
Why is this research important?
• Because no other researchers seem interested
in asking these questions
• Because we base our evidence on in treatment
populations and those who experience
treatment’s ‘revolving door’
• Because of an increasing commitment to
treatment careers and completions
• Because of the salience of ISG clients in
treatment services, failure is over-stated and the
biological model dominates
Are there windows with
increased opportunity for
recovery?
Intensity/
Severity
Harm min (MMT/BMT)
Prolonged dependence/
learned helplessness
Predependence
Maturing out
(Escalation)
(De-escalation)
Positive
Negative
Low motivation
Higher motivation
Burned bridges
Not imbedded in crime
Still pleasurable drug use
Tired of lifestyle
multiple morbidity
Non-dependent
Substitution activities (CM?)
Amenable to change
Few life opportunities
Positive
Negative
Still life options
Time
Is there a window for recovery?
…. And does it fit with a back door to the treatment
services?
Evidence biased in favour of maintenance but
little done on routes out of addiction and on
supporting long-term recovery
Aftercare?
Housing?
Employment?
Can treatment and mutual aid be reconciled
effectively?
So why has treatment contributed so little
to the process of recovery?
Failures of evidence
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•
Tier 4
Aftercare
Community detoxification
Complexity of treatment journeys
Failures of joint working
• Leaving us with an evidence base predicated on
the medical / biological with little knowledge of
social factors that predict success
Conclusion
• Drug treatment has become a population
management strategy
• Failure is salient and success is hidden
• Only recently is abstinence becoming an
acceptable aim to clinicians
• Irrespective of intensity and severity, addiction is
a career, not a chronic, relapsing condition
• The key is recovery journeys that emphasise
routes to abstinence and mechanisms for
maintaining it
Tier 1
PRIMARY CARE
/PSYCHIATRY
Tier 3
Tier 2
Tier 4
NEEDLE
EXCHANGE
DSB
DIP TEAMS Total =344
HOUSING
SERVICES
OUTREACH
HoB
N=126
North
N=38
South
N=178
East
N=102
Shared
Care
N=1101
CDT’s Total=761
PROBATION/
COURT/
POLICE
PRISON
CARAT/
INREACH
INFORMATION
&
ADVICE
SERVICES
DRUGLINE
DAYCARE
EXIT
Slade Rd
N=203
Azaadi
N=239
Barker St
N=143
Mary St
N=176
BRO-SIS
OTHER
Criminal
Justice
N=135
INCLUSION
Total Across
Service n=119
SAFE
ADDACTION
Movement through system in both directions
INPATIENT
The Outcomes Star
And finally ……
• Addiction careers are not predictable but this
study suggests that we do not have to commit to
the ‘chronic relapsing condition’ mantra
• It is crucial that this message is disseminated to
users and to workers alike
• Treatment purgatory cannot be perceived as a
desirable state of affairs
• We need the evidence to promote this through
policy mechanisms