LEGISLATING FOR ADDICTION RECOVERY

MAKE THE LAW WORK FOR YOU

Are the much-lamented addiction-treatment structures in the NHS lawful? UK Advocates has sought legal advice on improving treatment and access to it– and is about to apply for a judicial review. Robert Beckett makes the case.

I started UK Advocates last year with one specific purpose. UKA and its growing number of members and supporters are demanding that all alcohol dependents in the UK have, as a legal right, free access to the kind of intensive, abstinence-based, 12-step oriented treatment that not only allows them to get sober but also equips them with the tools necessary to stay sober and resume a useful and fulfilled life.

UKA was conceived after I returned from 10 years in the US advising the alcohol-treatment sector, particularly on the east coast. I was appalled to find that the treatment offered to still-suffering alcoholics had at best stood still and at worst gone backwards since, 21 years ago, I helped to establish the first public/private alcohol treatment centre at what was later to become the Nottingham Priory.

The type of treatment we are demanding be made universally available in the UK is the norm in other parts of the western world. One look at the models of access and care and the level of positive outcomes in the US, New Zealand or Germany put standards here to shame.

We have a situation where alcohol dependents, ranging from the early to chronic stages, are too often offered only controlled-drinking programmes and/or powerful psychoactive medication while still drinking – despite manufacturers’ guidance – with a void where abstinence-focused treatment provision should be.

So UKA has been seeking an opinion by leading London Queen’s Counsel on whether   or not the prevailing treatment structures in the National Health Service are lawful.

MEDICAL NEGLIGENCE

On the basis of counsel’s advice, we believe that there is a strong case that current treatment regimes are challengeable on the grounds of both medical negligence and maladministration.

With counsel, we are also exploring possible contravention of basic human rights.

The first part of the potential action centres on patients who allege medical negligence as a direct result of a failure by clinicians to diagnose their alcohol dependency. They were treated in NHS units that send alcohol dependents to treatment that involves further drinking.

Instructing solicitors state: “In the absence of a liver biopsy examination which, according to a paper of the Royal College of Physicians entitled The Medical Consequences of Alcohol Abuse is the only certain method of determining the presence of liver damage, clinical and laboratory signs being unreliable in themselves, the only professional direction would be one of complete abstinence.”

Based on this, Counsel opined: “It should be within the knowledge of any body which purports to offer advice on alcoholism and alcohol problems that liver damage is a frequent effect of alcohol abuse. If such a body advocates the continued use of alcohol, albeit at a reduced, “controlled” level without advising the client to abstain completely until liver damage has been ruled out, and as a result of continuing to drink the patient dies or sustains further damage, then that body may well be liable.”

The cases of these ex-patients are under review by their solicitors. Any subsequent action will be taken in court against the various Primary Care Trusts, as the commissioner and purchaser of alcohol treatment services in the respective areas.

GPs might have a defence if appropriate services had not been commissioned by their employers – the local PCT.

JUDICIAL REVIEW OF PRIMARY CARE TRUSTS’ MALADMINISTRATION

The second part of our legal challenges is linked, but requires establishing a systemic administrative failure. This is evidenced by the almost complete lack of clearly defined abstinence-based treatment programmes that comply with the World Health Organisation’s International Classification of Diseases 10th Edition in situations where a patient requires to stop drinking.

We intend to make an application to the Administrative Division of the High Court for judicial review once the outcomes of the class action cases are known.

We will argue that the current situation forces GPs and healthcare professionals to refer an alcohol-dependent person to treatment programmes which condone further drinking, contrary to all best-practice guidelines.

The World Health Organisation’s ICD-10 defines and sets out the criteria for the diagnosis of alcohol dependence. It clearly states that a return to further drinking can worsen the symptoms of the disease.

We believe that the NHS is failing in its administrative duties to provide clinicians with a suitable abstinence-based alternative, and that this is an error at law. We are advised that this practice is out of line with United Nations and WHO protocols to which the UK government has been a signatory for many years.

The prospect of taking those responsible for commissioning alcohol services, namely PCTs and ultimately the Secretary of State for Health, through the courts might seem daunting to some, but not to us.

The law is our servant and there to be used by citizens as a last resort wherever the will of Parliament and European law is resisted.

Action is not being taken lightly. It is nothing to do with punitive measures against anyone, jury trial or imprisonment. We are basically saying “Look, we have tried to impress on PCTs that what they are doing is wrong but they don’t appear to be listening. Now explain to this judge why there is virtually no abstinence treatment available to help the one million people a year being admitted into trust hospitals for alcohol-related illness”.

We know there is a great deal of support in the alcohol treatment and clinical community for our aims. But many have to exercise restraint when voicing their opinions precisely because they come from within, or are tied into, this failing system.

Here is where UKA has the advantage. We have no such dilemma. We are a not-for-profit registered limited company, autonomous from other organisations.

As independent as Addiction Today, UKA can act as the battering ram for all those chipping away from the inside at a chaotic and discredited system that is screaming out for change.

Our targets are not GPs nor the NHS in general. In fact, Tier 1, 2 and 3 provision for potential problem drinkers is generally good. It is at the crucial fourth tier, where abstinence must be the primary goal, that there are mandarins and others who still hold on to the dangerous and bankrupt belief that drinking alcoholics can be managed and moderated.

This is at a time when hospital admissions for alcohol-related illness is costing the NHS £3billion every year during a deep recession, when alcohol has been identified as the prime killer among women under 35 and a major contributing factor in one in 20 deaths in Scotland. Maintaining the status quo is not an option.

MULTIPLY EFFECTIVE SOLUTIONS

Abstinence-based treatment, centred on the 12-step programme and allied to intensive behavioural cognitive and motivational therapy, works.

We know it works. Read the research. Or go to any alcoholics’ self-help meeting and listen to the number of people with strong sobriety who return to happy and productive lives after structured 12-step abstinence treatment.

An audit of sample provision carried out by UKA of PCTs in the Trent region identified only one PCT, Nottingham, as offering this model of intervention. Only a handful of others indicated they might be willing, far less actively seeking, to provide it. We believe this applies across the UK.

Currently, most patients who get this vital, life-saving treatment are either those who can afford it or who have committed repeated criminal acts under the influence of alcohol and are ordered to it by the courts. The average person in the street without deep pockets, who has done nothing wrong but succumbed to the disorder of alcoholism, is effectively excluded.

It is little wonder, perhaps, when you see those charged with implementing treatment policy merely papering over the deepening  cracks.

Peter McDermott, a board member of the government’s National Treatment Agency for Substance Misuse, contradicted the findings of his own organisation and the Commission for Social Care Inspection¹ when he told The Observer that “Residential rehab doesn’t actually work very well”.

Indeed, for the benefit of official figures, someone receiving only one hour’s counselling a fortnight, often allied to a controlled drinking programme, is considered “in treatment”.

ICD-10 AND MOCAM OBJECTIVES

Even more galling, and central to UKA’s case, is the fact that treatment provision in this country flies in the face of international guidance and the government’s own objectives and policies.

WHO’s ICD-10 states: “For those dependents who have reached the stage whereby their drinking has become uncontrollable, harmful to self and others, specialist treatment is necessary. In order to arrest any further damage caused by alcohol consumption the patient first needs help to stop further episodes of drinking… with a long-term sobriety as its primary goal”.

The Department of Health’s 2006 Models of care for Alcohol Misusers could hardly be clearer: “Abstinence will be the preferred goal for many problem drinkers with moderate to severe levels of alcohol dependence, particularly for individuals whose organs have already been severely damaged through alcohol use. Commissioners should ensure local treatment systems are able to respond to severe and recurrent cases”.

Call it a disease or disorder, an illness, call it what you like, alcoholism is blighting the lives of ever-increasing numbers of people and the suff erer is being treated with contempt.

Vested interests quote a dearth of detailed research into the precise long-term success rates of intensive 12-step abstinence treatment in specific centres, which struggle to fill in unsuitable NTA TOP forms, but the large-scale empirical as well as anecdotal evidence is overwhelming.

The only hope for the UK recovering from this fatal epidemic is the wholesale provision of Tier 4 cessation programmes that lead to service exit and full life in a recovering community.

REFERENCES:

¹ Commission for Social Care Inspection & NTA: www.addictiontoday.org/addictiontoday/2009/03/tier-4-review-rehabs-jan-2009.html

² Questions the NTA declines to answer: www.addictiontoday.org/addictiontoday/2009/01/questions-the-nta-must-answer.html

Comments

[Peter O'Loughlin]

Congratulations on your intiative to right a long standing wrong

Abstinence based or focused treatment appears to be alien in concept to both the DoH and the NTA as witnessed by the former's lack of provision for it in their published alcohol strategy which rejoices in the contradictory title of 'Safe, Sensible and Sociable and on virtually every page carries the message that,"more needs to be done to promote sensible drinking". Given that the first organ in the body to be adversley influenced by alcohol is that part of our brain which controls our ability to make rational judgement and, which for that reason drink driving is outlawed in many countries, that message is not only paradoxical, it might be considered irresponsible.

it is also a fact that the NTA show little support for abstinence focused treatment of alcoholism, or other drugs, with their cliches of 'one size does not feel all' and 'abstinence is not for everyone' and most insulting of all, 'recovery is a process, not an event'. Really? Who would have guessed?

The efficacy of 12 step programmes on the other hand, is widely documented, as is Prochaska & DiClemente's 'Process of Change, it is interesting to note how the former fits so elegantly into the various stages of the latter and as someone who routinely implements both in his practice, I am convinced that more widespread use of integrating both models would result in considerably more success than the 'controlled drinking' enthusiasts could ever begin to conceive.

For those in the front line to undertake interventions such as that, would require not only considerable training, but equally demanding changes in the current ideology which is the hallmark of both the DoH and the NTA's failure to successfully treat, the admittedly intractable condition of alcoholism.