The end of addiction careersThe end of addiction careers

DR DAVID BESTUNIVERSITY OF BIRMINGHAM

BIRMINGHAM DAT / NTA

Treatment WORKS!Treatment WORKS!

• DARP• TOPS • DATOS• NTORS • DORIS

• TREATMENT INTENSITY • ENHANCED SERVICES

What Do Eminent International What Do Eminent International Experts Tell Us?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 DupontDirector of NIDA

1993

““A Chronic, Relapsing A Chronic, Relapsing Condition”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 People receive around 45 mins of contact time per fortnight or 18 hours contact time per fortnight or 18 hours

per year …per year …13.7

11.710.6

10.6

Case Management Links to other servicesTherapeutic Activity Other

Best et al (submitted )

Therapeutic Activity

% 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%

Numbers in treatment Numbers in treatment

0

50,000

100,000

150,000

200,000

250,000

300,000

350,000

2003/04 2004/05 2005/06 2006/07

Numbers in treatment

Drug strategy target

Glasgow estimate

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%)

Number of PDUs completing drug treatment as a proportion of Number of PDUs completing drug treatment as a proportion of discharges and completionsdischarges and completions

Cultural effects of this modelCultural 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 What has gone wrong with structured day treatmenttreatment

TARGETS

Quantity Over

Quality

Methadone based

treatment

Methadone, wine & welfare

Models of chronic, relapsing condition

Instrumental working

Morale collapse & contagion

Working in a tap factory

A clash of objectivesA clash of objectives

Public health and safety OR

Individual wellbeing

The subtle incompatibility of goals across the addictions career

4051 53 59 57

0

20

40

60

80

100

Pre-Trt Yr 1 Yr 2 Yr 3 Yr 6 Yr 12% in Years After Treatment

No Jail/Daily Drug Use No Jail/Daily Drug Use (Male Opioid Addicts in DARP)(Male Opioid Addicts in DARP)

N=405; Simpson & Sells, 1990

3 Years3 Years

Drug Use Outcomes: Drug Use Outcomes: Community TreatmentCommunity Treatment

Abstinent from all drugs

Abstinent from illicit opiates

Occassional opiate use

Frequent opiate use

Daily opiate use

0

20

40

60

80

100

Intake 6 months 1 Year 2 Years

%

Abstinent from all drugs Abstinent from illicit opiatesOccassional opiate use Frequent opiate useDaily opiate use

Drug Use Outcomes: Drug Use Outcomes: ResidentialResidential

Abstinent from all drugs

Abstinent from illicit opiates

Occassional opiate use

Frequent opiate use

Daily opiate use

0102030405060708090

100

Intake 6 months 1 Year 2 Years

%

Abstinent from all drugs Abstinent from illicit opiatesOccassional opiate use Frequent opiate useDaily opiate use

End Of Careers StudyEnd 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 CareersCompleted Heroin Careers

0

5

10

15

20

25

30

35

age of firstuse

age of firstdaily use

age of peakuse

age of lastuse

age

What finally enabled What finally enabled participants to give up?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 What enabled people to maintain abstinence? 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 dataQualitative 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 workFollow-up work

• 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 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 Reasons for staying abstinent

Support from friends 32 (50.8%)

Moving away from substance using friends

34 (54.0%)

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?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 Why is this research important?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

Intensity/Severity

Time

Are there windows with increased opportunity for recovery?

Pre-dependence

(Escalation)

Harm min (MMT/BMT)Prolonged dependence/learned helplessness

Maturing out

(De-escalation)

Positive Negative

Still life options Low motivation

Not imbedded in crime Still pleasurable drug use

Non-dependent Substitution activities (CM?)

Positive Negative

Higher motivation Burned bridges

Tired of lifestyle multiple morbidity

Amenable to change Few life opportunities

Is there a window for Is there a window for recovery?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 recoveryAftercare?Housing?Employment?Can treatment and mutual aid be reconciled effectively?

So why has treatment So why has treatment contributed so little to the contributed so little to the

process of recovery?process of recovery?

Failures of evidenceFailures of evidence

• 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

ConclusionConclusion• 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

Movement through system in both directions

DAYCARE

EXIT

Tier 2 Tier 3Tier 1 Tier 4

PRIMARY CARE/PSYCHIATRY

PROBATION/COURT/POLICE

PRISON

HOUSINGSERVICES

OTHER

NEEDLEEXCHANGE

CARAT/INREACH

OUTREACH

INFORMATION &

ADVICESERVICES

ADDACTION

INPATIENT

DSB

CDT’s Total=761

SAFEINCLUSIONBRO-SIS

DRUGLINE

DIP TEAMS Total =344

HoBN=126

NorthN=38

EastN=102South

N=178

SharedCare

N=1101

CriminalJusticeN=135

Slade RdN=203

AzaadiN=239

Barker StN=143

Mary StN=176

Total Across Service n=119

The Outcomes StarThe Outcomes Star

And finally ……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