QUESTIONS THE NTA DECLINES TO ANSWER
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1. WHERE ARE THE 65,000-70,000 PATIENTS NOT IN REHAB NOR ON SUBSTITUTE MEDICATION?
NDTMS figures, given in a 2008 parliamentary question, confirmed that 131,468 people in the last year received methadone or buprenorphine. But only about 2% (about 4,000 patients) are referred to rehab, and there are even fewer psychosocial daycare programmes -- which means that 65,000-70,000 patients are unaccounted for. What percentage of the 65,000 are people seeking help forced to wait 12 weeks between an initial appointment and a second one, who are then labelled as being in "12 weeks retention"? An independent audit could perhaps shed light.
2. WHY HAVE DRUG DEATHS RISEN?
The titles of these reports are self-explanatory: Male drug poisoning deaths highest in five years: Health Statistics Quarterly autumn 2008 published by the Office for National Statistics and Drug-Related Deaths in the UK - Annual Report 2008: Increase in the number of Drug-Related Deaths, published by the International Centre for Drug Policy at St George's University of London. Widespread prescribing was justified as avoiding such results as are listed in these reports; furthermore, 20% involved methadone.
3. WHY DID THE NTA DENY THE EXISTENCE OF ITS OWN TIER-4 NEEDS ASSESSMENT?
Addiction Today wrote to the NTA saying that "Another success story we would be happy to feature in an article is: What activities, and with what results, did the NTA undertake to implement the actions and recommendations from its own commissioned piece of work on Tier 4 needs, researched by David Best". We also offered to feature similar research by Ed Day on detoxification provision. NTA communications director Jon Hibbs responded about "the mysterious non-existence of any substantive piece of work from either Ed Day or David Best on the subjects you mention. We can't publish what we don't have".
Addiction Today managed to track down the research, which belongs in the public domain:
Download National needs assessment for Tier 4 drug services (1.07Mb)
Download Tier 4 drug treatment-inpatient provision and needs assessment
4. WHY IS THE NTA DENYING THAT REHABS HAVE CLOSED?
About 19 rehabs in the UK closed and others made counsellors redundant. Most depend on the state for clients – but it refers only 2% of drug abusers to drug-free treatment, creating a crisis of empty beds and waiting lists of people desperate to fill them.
This is not an issue of harm reduction / abstinence - it is about bad practice versus good practice.
The disproportionately low 2% of referrals also signifiies denial of patient choice. According to researcher Dr David Best, a new phenomenon has arisen: people who want to get off drugs are now afraid to approach agencies because they fear substitute drugs will be pushed onto them instead.
In the hope of raising awareness and working together for solutions, Addiction Today started posing questions to the National Treatment Agency for Substance Misuse in October 2008. Disappointingly - given this charity's seven years of unswerving support for the NTA - the NTA instead communicated to organisations in the field that "On Addiction Today,... the magazine/website could not be trusted as an impartial source because it misrepresented the NTA's position on a variety of issues, not least residential rehab... it would be worth checking out the status of AT's claims about closures with the organisations themselves".
Not getting through on telephone or website for the defunct organisations is an answer in itself. The list of closures is on the home page at www.addictiontoday.org.
5. WHY DOES THE NTA DENY EMPIRICAL RESEARCH THAT REHAB WORKS?
Professor David Clarke of Wired has written of “a local commissioner who was telling drugs workers that research showed that residential rehab did not work. Therefore, local commissioners were not going to send people to residential. Very worrying was the fact that the drugs workers believed what he was telling them! No wonder residential centres are struggling to fill their beds, with this disgraceful misinformation”.
The same adjective could be applied to the NTA head-office staff member who unjustifiably told BBC home editor Mark Easton, when researching a programme, that “there is no evidence that rehab works”.
The £90,000+annual-salaried NTA communications director Jon Hibbs also posted comments on this website denying empirical research - click here. And NTA board member Peter McDermott stated in The Observer last November that "Residential rehab doesn't actually work very well" alongside other negative comments.
The NTA has a stated aim of getting people off drugs – but this must surely be mere lip service when millions of pounds in each of its seven years have not been utilised to give its own staff accurate, life-saving information. Incidentally, the NTA was given £8million to spend on staff and over £3million to spend on consultancy, according to its latest annual report.
6. When is £54million not £54million?
When the NTA. recycles a two-year old press release with an unusual juxtaposition of words and figures. Click here for details.
7. Why is the NTA funding an organisation - one of whose directors is a NTA director - without inviting tenders?
This is a more recent question, posed by Peter O'Loughlin of Eden Lodge. "Why is the NTA 'part funding' a study commissioned by the UKDPC to examine employers' attitutdes to recruiting ex-drug users, rather than inviting tenders? Has the Confederation for British Industry or the Small Business Organisations been approached for advice?".
8. ARE FIGURES AUDITED? HOW?
Minutes from a NTA board meeting show that its senior managers’ salaries, including its CEO’s, are directly linked to outcome targets. So there is a keen interest in the figures being presented to show that targets have been met – but this can act against getting both the right figures and the right kinds of figures. The figures rely on the Top ‘validating’ paper which independent researchers describe as measuring only reliability of crime – ie, consistency of self-report, not validity.
So, clients underreporting drug use and off ending at structured interview, due to stigma and fear of consequences… combined with workers not asking relevant questions... will lead to… targets appearing to have been met. Addiction Research & Theory plans to publish a peer-reviewed paper on this in Spring.
9. If the NTA can do nothing about residential rehab, why is it doing so little about community rehab?
10. Why do NTA figures not differentiate detox and rehab?
Figures are blurred when detoxification and psychosocial treatment are referred to in the same sentence as "abstinence treatment". The two are very different, with very different goals and outcomes, and perhaps with different types of diagnoses. Expenditure and outcomes relating to each should be given discretely.
11. How many patients are diagnosed with addiction/dependency? How many people are diagnosed as having substance abuse?
Why are we unable to find these two types of patient quantified in the NTA figures? After all, if there is no accurate diagnosis, how can optimal careplans be prepared and implemented?
12. Why are we unable to find numbers of patients with accompanying mental disorders?
13. Where are the figures demonstrating that more chronic, complex clients go to rehab?
This is clarified in NTORS and other empirical research but not in NTA figures.
14. When will the figures showing drug-free clients actually link them with the treatment they receive?
Only then can anyone know what works.
15. How many of those who have "successfully completed treatment" are now in paid employment?
16. Why have drug offences risen?
How does NDTMS measure this?
18. If there is a ‘third way,’ what budgets are spent on training, and in what, to sustain recovery paths?
What is the evidence base for this middle way?
19. Does the TOP measurement tool answer these questions? If not, why not?
If Top and NDTMS do not answer these questions, they should be replaced – was Top sent out to tender? Was its review sent to tender? And was it peer reviewed to answer the questions above?
20. Who is accountable - the NTA or Local Authorities, PCTs, Dept of Health?
I was among those who regarded the NTA as responsible for only 2% of people getting into drugfree treatment, particularly as it takes credit for “getting 202,000 people into treatment” in its press releases. However, three of its senior people stated the responsibility belongs to PCT/LA commissioners. “They hold the budgets.”
The NTA annual accounts confirm this: last year, it spent £14,517,000, not one penny on treatment.
However, budgets for treatment are not released until the NTA approves them. Despite advocacy, it has not set a target for drug-free treatment admissions, nor people getting drug-free.
But NTA regional manager Mark Gilman achieves outstanding good practice (in comparison; 7% of patients get the drug-free treatment they seek). Why is his paradigm not replicated nationally?
There are many more questions we would like to ask, but 20 is a more realistic target on which to start the new year. Perhaps answers will be forthcoming in 2009, as they were not in 2008.
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THE RESEARCHER’S EXPERT VIEW
Dr David Best was formerly research manager for the National Treatment Agency, so was uniquely qualified to debate appropriate treatment with the NTA. He gives a summary below of his research.
“Most clients don’t want methadone and certainly don’t want it for life
The evidence base for England shows no reductions in alcohol or crack use – and some start both after entering methadone ‘treatment’.
Problem drinking exists in up to 40% of methadone maintenance clients.
Maintenance works but only when it is part of a package – people typically get seen for 1.5 hours a month and receive evidence-based psychological interventions for less than four hours a year.
Can methadone maintenance work? Not using the NTA model of maximising numbers without delivering meaningful treatment...
Even the most ardent proponent of maintenance has no idea about an ‘evidence-based’ model for the transition/exit from maintenance.
Meanwhile, the client is increasingly coshed by sedating effects of the drug and its long-term impact on decision making and planning – precisely the personal resources required to overcome long-term addiction.
For all the outcome studies, we have no data on the proportion of clients who are the “models of maintained recovery” that we hear so much about – the golden eggs of the maintenance system who are not readily found and have never been quantified by any brave scientist... and a zero score on Top does not count as reliable evidence!
NTORS and all major outcome studies suggest that abstinence is a viable goal, achieved by large numbers in spite of the scandalous lack of funding for rehab and recovery journeys (48% abstinent after two years, compared to the NTA 2%).
Finally, in a time of concern about children of drug-using parents and Every Child Matters, is maintenance becoming a heritable curse of stigma, underachievement and decay?
there are quite a few issues I have with this list as much of it seems to be a rant. However I suppose what angered me most was the bit on crime. Levels of violent crime are not indicators of drug realted crime as alcohol is the biggest substance factor in this. Also drug offences are only part of the picture as the main target of a treatment was always acquisative crime. Drug offences are misleading as the majority are usually for drugs which are not directly targetted under the drug strategy such as cananabis. I think I am right is saying drug realted acquisative crime has actually fallen
Posted by: jim barnard | January 16, 2009 at 12:33 PM
Excellent set of questions - but who will answer them? Having fought hard to get two clients into residential rehab against local DATs not wanting to pay the fees I am sure that many drug users who want such treatment are being denied the choice. Following 6 months of rehab one young man was clean for 16 months. Then had a relapse due to lack of ongoing support - but is now back on track with the help of privately financed counselling.
Who can explain to me how the NTA
can spend £14.5 million pounds but none of that on treatment ?
What is the Audit Commission doing about that revelation?
The UK desperately needs more residential rehabs not less - the NTA is denying thousands of drug users the opportunity to become ex-users.
Posted by: Ann Stoker | January 16, 2009 at 12:34 PM
Interesting piece. Kind of. In parts. Its just a shame that some good and constructive points are mixed in with a lot of stuff that really has no purpose beyond making political capital. For example, it *was* a curious move to reannounce the £54 million investment in residential treatment as though it was new money and there certainly are questions worth asking about treatment outcomes. However, stuff like "What Dat systems support people in abstinent recovery?" and "If there is a ‘third way,’ what budgets are spent on training, and in what, to sustain recovery paths?" are not only incoherent and therefore entirely pointless, but also detract from some of the important issues. Additionally questions about internal research, tendering policy etc may be appropriate - but in this format they just look like griping and bitching. As someone who has often been an outspoken critic of the NTA I can understand many of your frustrations, however, progress won't come by setting organisations up as the targets for attack. These issues are too important for that. If you feel its necessary to have a focus on the NTA you actually need to take a critical look at its work and assess what progress it has made firstly to its own objectives and secondly to the broader and maybe more pertinent goals of improving the quality of life and the treatment experience of people who experience problems with substance use. This piece doesn't do either. It just makes it look like the whole of the residential sector is feeling hard done by and wants to get its own back.
One of the things I've actually been wondering is that maybe the demand for residential treatment is down and therefore rehabs closing BECAUSE there is so much greater availability of better quality community treatment?
Posted by: Sara McGrail | January 16, 2009 at 12:40 PM
Why is Ms McGrail so defensive about what is, after all, only a set of questions? Or, rather, about a couple of minor questions near the bottom of the list. As she rightly says, they are constructive. We all have a right to the answers. And if the NTA had supplied the requested information months ago, the questions would not be posted here as an encouragement to supply the answers.
Let's not lose sight of the key questions: where are the one-third of people said to be in treatment but have not been accounted for? Are they and others getting the help they need? Are their families?
We should all be working together to find the answers, then on solutions for any problems they might throw up.
Posted by: Laurence McMorrow | January 17, 2009 at 10:13 AM
Sara McGrail poses a valid point of view together with an interesting question
"If you feel its necessary to have a focus on the NTA you actually need to take a critical look at its work and assess what progress it has made firstly to its own objectives and secondly to the broader and maybe more pertinent goals of improving the quality of life and the treatment experience of people who experience problems with substance use"?
So let’s do that, although it is actually difficult to do so since the objectives of the NTA tend to be fluid in the sense that they appear to change in order to make them compatible with whatever results they achieve, or the latest political ‘initiative’
One of the oft repeated claims of the NTA is that its treatment strategies are based on evidence. Whilst this is true, it fails to acknowledge that the vast majority of that evidence is selective in the sense that it is designed to support so-called harm-reduction strategies which are patently failing.
A classic example is the increase in drug deaths and especially those related to methadone use. One of the key goals of the NTA is to reduce drug deaths; and whilst it claimed in its 2008 report to have done this, it failed to mention that it had not met the targets.
When Paul Hayes addressed delegates at the annual NTA conference last year, he emphasised that "harm reduction services are vital if drug users are not to suffer avoidable illness and death" and claimed "we have stopped the sharp increases in drug related deaths". This characteristic smoke and mirrors piece of spin sought to suppress the truth of the increase in drug deaths during 2003-4 which were attributed to heroin morphine and methadone.
Nor did Hayes bother to mention the fact that that the mortality rates were highest among the young.
I could fill 10 pages, Sara, with how the NTA is not achieving its own objectives, which may be because it appears to be more interested in redefining recovery to include ongoing drug use, rather than actually achieving the much more difficult task of facilitating drug-free recovery for the vast majority of service users who, according to the NTA, wish to engage in a drug free recovery.
Notwithstanding that evidence and the evidence that methadone is a highly addictive drug, together with an abundance of research such as that provided recently by Professor Neil McKegany which clearly establishes that those engaged on MMT continue to commit crime and use other drugs, the NTA defends its position by pointing to the NICE recommendations -- but fails to point out that NICE whilst, advocating the use of it, emphasises the need for parallel psychosocial interventions together with encouragement to attend self help groups.
One has only to look at the stories of recovery on ‘Wired’ to be aware of how little attention is paid to the latter.
Now what about that "pertinent goal of improving quality of life"? Apart from the anecdotal evidence of ex-service users posted on Wired, one could be forgiven for suggesting it would not be in the interests of the NTA to dwell for too much or to long on that subject.
But since anecdotal evidence may not always be reliable, let's have a look at the facts.
Assuming they don’t die from the common practice of combining methadone treatment with alcohol and other drug abuse, those on MMT can expect to experience the following:
Drowsiness, nausea, dry mouth, constipation, difficulty in passing urine. respiratory depression, hypotension, feeling of unease, restlessness, agitation, or just feeling generally unwell, hallucinations, mood swings, rash or itching, decreased sex drive and arrhythmias.
In fairness, since ‘quality of life’ is both subjective and relative, it is possible that some of those who are locked into MMT are willing to tolerate such unpleasant effects. But it is difficult to see how they can be expected to comply with the ‘objective’ of getting users back into employment. So perhaps, Sara, the questions raised in this blog are more relevant than they may at first appear to be, or that one may wish to acknowledge.
Jim Barnard’s comments regarding alcohol are also interesting. Leaving aside the official statistics which indicate that alcohol is responsible for 40 per cent of all violent crime, let’s face the truth that poly substance use including alcohol is more prevalent than not. And I have seen little evidence that those on MMT are discouraged from that practice.
Jim’s view that much of the drug-related crime is due to cannabis and other substances, not targeted under our current harm reduction strategy, may be accurate -- but since it is also a key objective of the NTA to reduce drug use and drug crime, this is in itself a damning indictment of the current strategies.
I would also point out that the Metropolitan Police Crime figures for 2007-8 indicate a staggering 73 per cent increase in ‘drug offences’. Thus, the questions raised are even more relevant; however that, regrettably, will not be sufficient reason for the NTA to address them.
Posted by: Peter O'Loughlin | January 17, 2009 at 02:42 PM
Jim Barnard says"I think I am right is saying drug realted acquisative crime has actually fallen" if this were the case i would put it down to the fact that the price of drugs has fallen also, see any connection?
sarah says What Dat systems support people in abstinent recovery?" and "If there is a ‘third way,’ what budgets are spent on training, and in what, to sustain recovery paths?" are not only incoherent and therefore entirely pointless, but also detract from some of the important issues.
These questions are totally cohearant to me and also extremly important. As for your parting shot "One of the things I've actually been wondering is that maybe the demand for residential treatment is down and therefore rehabs closing BECAUSE there is so much greater availability of better quality community treatment?
That just made me squirm at your ignorance.
Would be interesting to see the NTA attemp to answer thse very important and in my view well put questions.
Posted by: Annemarie Ward | March 27, 2009 at 02:01 PM
Its good that someone's asking tough questions, but now the NTA's answered them be fair and publish their responses.
Come on Addiction Today, failure to show the whole picture starts to look like propoganda rather than balanced reporting
Posted by: Jon Royle | November 04, 2009 at 04:19 PM
Jon Royle raises a very relevant point.
The NTA has been given £20million of our taxes a year, a large chunk of of which it spends on PR/damage-limitation staff - yet it took all those staff over a year to publish Addiction Today's questions and respond to them.
Addiction Today had a donation of £1,000 in the last financial year, £500 in the year before; it takes little guesswork that its few staff devote much of their time/overtime for free. They handle over 1,000 life-or-death help calls every year (many from families let down by the NTA regime), in between which we do other valuable charitable work. And Jon Royle expects us to be able to drop everything to accommodate his request in a fraction of the time it took the NTA with its vast resources (to which ARF taxes contribute).
But rest assured: Addiction Today will respond, and in less than 8% of the time it took the NTA.
Posted by: Deirdre Boyd | November 04, 2009 at 05:49 PM
Save your time: anyone who wants the NTA stuff can go to its website. It also publicised itself via DS Daily.
I got so tired reading the NTA wriggling and subterfuges - I don't know how you have the energy!!!
Posted by: Laurence McM | November 04, 2009 at 06:03 PM
Having left the Board of the Addiction Recovery Founation some years ago, I have continued to follow the fortunes of the organisations and its message.
This week I learned how my understandings of addiction and recovery differed so much from the medical 'experts' and how much the 12 step message needs to be spread to those experts.
Any assistance that I can give to the Addicton Recovery Founation in the future I will feel fortunate to do.
Posted by: Redmond Walsh | November 20, 2009 at 12:08 AM
Dear Addiction Today,
Congratulations for questioning the NTA,thank goodness someone is beating the drum for the Rehab sector.In 20 years of working in tier 4,this is the bleakest time i have known for our sector.Despite millions being spent in the drugs field it is harder now for a client to access detox and rehab than at any time in the last 20 years.
R Woznicki
Posted by: Robin Woznicki | November 20, 2009 at 12:05 PM