BBC RADIO4's TODAY SHOW, 2 October 2008

“TREATMENT WORKS” – BUT ONLY IF IT IS APPROPRIATE, BEST-PRACTICE TREATMENT.

John Humphries and Mark Easton interviewed National Treatment Agency CEO Paul Hayes on BBC4 Radio’s Today programme on the morning of 2 October 2008. Below are some corrections to Hayes’ responses.

EDITORIAL OVERVIEW.

Addiction Today’s view is that the argument should not be about abstinence versus harm reduction but about good practice versus bad practice. Both abstinence and harm reduction options should be offered appropriately, after accurate assessment, using best practice in treatment for the ultimate good of the patient – and, ultimately, their families, employers and society. But placing only 2-4% of patients in rehab is NOT proportionate nor a level playing field.

The Today programme has been recorded here - make up your own mind.

IS REHAB REALLY MORE EXPENSIVE?

According to costings based on the government’s own NTORS study, four 4 weeks’ rehab incurs almost-identical costs to a year on methadone – the difference being that there are good success rates of patients leaving rehab drug-free after those 4 weeks. The patient on Today had been put on methadone for 10 years, which implies 10 times the cost.  The NTA has featured “service users” as speakers at its conferences who have been on methadone for over quarter of a century. That indicates 25 times the cost.

Also, that cost is for dispensing of methadone alone, without psychosocial support services. Whether patients seek harm reduction or abstinence services, they should be offered appropriate psychosocial support.

HOW MANY NEW PEOPLE ARE TREATED?

The fact that this morning’s interviewee – very brave of him – was on methadone for 10 years indicates that he has appeared in the NTA figures every year for a decade; service users at NTA conferences have been on methadone for 25+ years.  That means the patients shown in rehab are likely to be different, new people every year, but the methadone-maintenance people could be the same people year in year out, with minimal new people being treated.

This not an argument against methadone: just a plea that the true picture be shown. Measurement tools used by the NTA do not give a picture of how many new patients are being treated.

DEFINE “TREATMENT”.

Hayes referred to “treatment” without defining what that meant. A prospective patient attending only his/her first, introductory session can be defined by the NTA and its measurement tool as being given “treatment”.

Similarly, “12 weeks’ retention” in treatment can mean that the patients desperately needing help to address their drug use are referred to the Drug Action Team – who makes them wait 12 weeks for their next appointment. This is called... guess what... 12 weeks’ retention. This is not appropriate, good-practice treatment, whether you define it in harm reduction or abstinence terms.

DIFFERENT TYPES OF PATIENTS/USERS.

Also, the government’s own NTORS research concluded that the most difficult, chronic people were sent to rehab, the ‘easier’ ones to community services. The NTA measurement tool gives no indication of this, even though it is not comparing like for like.

Also, on the Today programme, Hayes referred every time to “addiction” and “addicts” not misusers. But many, perhaps most, of the patients seeking help are thought to be misusing/abusing drugs rather than being addicted to them. The NTA “measurement tool” does not show this medical differentiation - if they are there and we cannot see it, we welcome clarificationof the numbers.

These two different medical conditions require different treatment. If they are not being measured, are they being assessed accurately? Are they being diagnosed correctly? If not, there is no way of measuring that they are getting appropriate treatment.

Appropriate treatment for the two different conditions – addiction vs misusing – not only means more clinical effectiveness but also greater cost effectiveness. 

CROSS-ADDICTIONS.

NTORS also showed that 40% of the people on the methadone programme became dependent on alcohol, as the core issues were not being addressed. Again, this is about bad practice not whether harm reduction or abstinence is being used.

AGAIN, DEFINE TREATMENT.

Hayes said that methadone was a “gold standard” treatment. This might be in pharmaceutical terms, although subutox and other users would argue this - but it does not apply to therapeutic treatment. Nor did he specify for which type of patient might it be appropriate.

He added that NICE stated that treatment in the community worked as well as rehab. This directly contradicts the findings of the Audit Commission not too long ago. Also, at the start of this year the CSCI, the government’s Commission for Social Care Inspectorate, officially rated rehabs better than community/Tier 2 services.

WHY HAVE TREATMENT CENTRES NOT SPOKEN UP?

Simply, they have staff and current patients to safeguard. They fear that the Drug Action Teams will stop the few patient referrals they have or, if they have no referrals, that they will never get any. Many have contacted Addiction Today individually but will not speak out until a critical mass does so.

This uneven commissioning stokes artificial divides between providers, be they proffering harm reduction or abstinence services.

THE FUTURE.

We – for the sake of all patients who need help to address their drug using and consequences, and to help their families – advocate a measurement tool which will show us the types of patient presenting for treatment (dependent or misusing, other mental-health problems), so there is accountability for accurate assessment. We advocate a measurement tool which will show us the new numbers of people being treated each year. We advocate knowing how many leave treatment drug free – and that includes addiction/misuse of prescribed or over-the-counter drugs. We advocate knowing how many have become cross-addicted to another substance such as alcohol, and thus whether they are being treated for that.

This does not mean that we do not support other measures of treatment, such as stability in relationships, reclaiming their families, coming off benefits where appropriate. Of course we advocate measurement of these, and any other alleviation of harm.  But let’s get an accurate picture. I want to know that my hard-earned taxes are spent in the best possible way.

By the way, did the NTA measurement tool go out to tender? If not, why not? How much did it cost? Let’s get one which shows us exactly how our taxes do – or do not – help people. Accountability is a necessity for best practice.

Comments

[Peter O'Loughlin]

An excellent overview, not only of the need to identify essential differences in order to provide appropriate treatment, but also identifying the need to treat, where appropriate, the addicted, rather than the addiction.

Attempts to position treatment and recovery. as one and the same simply do not stand up to evidence based examination, nor does it add up to the oft repeated comment of Paul Hayes of using only ‘evidence based practice’, or ‘what works’. I therefore agree, it would be interesting to discover exactly what screening methods are used to identify ‘users’ as compared to addicted, together with the relevant numbers of each who are in treatment, and what differences there are in treatment protocols.

Not unconnected is an article by Rory Watson which appeared in the BMJ online journal, 25 September, EU updates its plan to reduce drug misuse, BMJ 2008;337:a1762, to which this writer posted a response, which in turn has sparked a debate. There is a link on my website www.edenlodgepractice.com Click on the link to 'Reducing drug use.'