Addiction Today: RESIDENTIAL REHAB BRIEFING: Barriers to access

by
THE CONCORDAT OF PROVIDERS OF FULL RECOVERY

Click Residential Rehab Briefing for Contents list of all 6 sections.
Or Download Residential Rehab Core Briefing May 2011

5. BARRIERS TO ACCESSING RESIDENTIAL REHAB

“It is ideological/extremist to recommend rehab/abstinence for everyone”
We are not suggesting that, but to rebalance the system so that it is equitable – at the moment, rehab referrals are falling and less than 2% of patients under the NTA regime manage to be referred to treatment. It would be more equitable for 25% of patients to be referred to proven rehab.
Few people get truly drug free, no matter how much they need it, because only 1.2% of problem drug users in contact with the drug-treatment system under the NTA enter rehab.
In 2008/9, it was 4,711 out of 202,000 users, or 2.3%. In 2009/10 numbers fell to 3,914 out of 320,000 users.
The figure could be lower. For the NTA RehabOnline list appears instead to be a medley of organisations which do not fit neatly into other categories.

“More people re-present to rehab than harm reduction”
Are they re-presenting or healthily progressing from detox to rehab to extended care?
Were they in rehab in the first instance?
Putting a variety of approaches including harm reduction under the heading of “rehab” gives the false impression that patients are re-presenting.

The effectiveness of rehabs is rarely recognised by commissioners.
Borrill et al (2003) found that application procedures for community-based rehabilitation services are complex and lengthy. ...prisoners were concerned that they would not be able to access a place in a rehab on release because of a lack of funding. (SevenResearch Studies, HORS 267, London:HO.)

THE FOLLOWING INFORMATION WAS GIVEN IN MARCH 2011:
• Gloucestershire had a treatment budget of £6million – with 1,000 clients on maintenance prescriptions and 6 (yes, six) in abstinence programmes.
• A procurement manager in St Helens wrote that “Tier 4 interventions [rehab] will not be provided... it is not envisaged that this will be a subsequent requirement”.
• Another area handed over its total commissioning to a single organisation which later had £1million deducted for not referring addicts to rehab in over a year.
• Camden has 1,200 clients on maintenance prescriptions; it had £300,000 to spend before the end of its budget year to 31.3.2011 but “no one to refer to rehab”.
• Nottingham has ended its contracts with 12-step-based organisations.
• Lincolnshire has stated it will not make rehab referrals.
• Bracknell, a Payment-by-Results pilot has stated it will make no rehab referrals.
• Manchester has stated it will send only 12 people to rehab in the coming year – ie, not based on an assessment of predictive need.
• Providence Projects in Bournemouth was refused Supporting People funding because its patients had become abstinent (!).

“NICE guidelines say we should not refer to rehab”
The Concordat has requested NICE to repeal its unilateral decision not to review NICE CG51 Psychosocial guidelines; it has been unanimously agreed to bring a Judicial Review if this is not reasonably dealt with. The key reasons are below.

Only 2% of people in the so-called treatment system are enabled to get drug free. This because the original document is life-threateningly flawed and must be AMENDED not merely updated/reviewed. In particular, Chapter 8 on Psychological Interventions omits 12-Step Facilitation which has been proven to yield the most clinically effective as well as cost effective service.

Clause 1.5.1.2 states that addicts who have had community-based psychosocial treatment cannot be referred to abstinent rehabs – thus fatally blocking continuum of care and sacrificing the principle of “first do no harm”. This clause has led to such incidents as patients being admitted to rehab after years on methadone and being found to have, despite reports saying no physical problems, broken clavicle and limbs, a stroke and vomiting blood (www.addictiontoday.org/addictiontoday/2011/01/successfully-leaving-treatment.html)

Point 1.5.1.2 is erroneous in a related context when it suggests that referrals to residential treatment should be restricted to those who have “not benefited from previous community based psychosocial treatment”. This contradicts the basis of treatment interventions being 'person centred' and flies in the face of experience which has shown clearly that gains from community-based psychosocial interventions can stabilise patients enough to be admitted to residential rehabilitation, leading to sustainable long-term recovery.

8.6.5 refers to “intensive referral” and links to 12-Step-based treatment programmes but it does not discuss the proven technique of 12 Step facilitation.

Payment-by-Results pilots will not refer to rehabs.
Rehabs as experts in full recovery have been excluded from PbR pilots.
Despite promises, they have been excluded from the Codesign phase of PbR pilots.
Only one PbR pilot seems to be willing to commission rehabs.
Harm-reduction agencies do have a role – but they are labelled as “rehabs” in some PbR plans.
The NTA and others are urging all commissioners to adopt the PbR pilot systems – before they have even been started, far less evaluated.

The Concordat has offered to be a 'control group' to compare its outcomes against PbR pilots.

There has been importance placed on methadone – but too many people are on methadone.
* Only about 2% of people in the treatment system are referred to rehab. It would be more equitable for this to be rebalanced to at least 25%.
* The methadone treatment expansion has proved riskier than anticipated, with drug misuse deaths up to 1,876 in 2009 and those involving methadone rocketing from 220 to 408, by 85% since 2005, constituting a quarter of all drugs poisoning deaths.
* Reported HIV infection among injecting drug users has risen for a decade – despite unprecedented investment in harm reduction drug treatment - with 90%+ of hepatitis C infection now acquired by injecting drug users.
* Research showed that being on methadone prolonged the median duration of this cohort of addicts drug 'injecting' careers from 5 to 25 years. This cohort (of 794 addicts followed over a 30 year period) also had prolonged poor health and poor quality of life.
* A PQ by Andrew Griffiths MP revealed that a quarter of the NTA's prescribing clients have been on state-sponsored methadone for more than four years and a half of them for more than two years.
* The reality of cross addiction is exemplified by NTORS where 40% of people on methadone maintenance became dependent on alcohol.
* Harm reduction, though driven by the principle of risk aversion, brings its own - and new - risks and costs. Leakage of prescribed methadone onto the illicit market is one. Death is another. Continued street drug and alcohol dependency and the welfare dependency are others.
* Previous cost-benefits and value-for-money calculations failed to recognise that most of the treatment population (79%), just like most of the problem drug-using population (81%), are unemployed and on benefits. Harm maintenance has not improved clients' employability.
* Claims made by problem drug users in 2006 for Job Seekers Allowance, Incapacity Benefit, Income Support, and Disability Allowance, calculated at today's prices, using median claims for each category, come to £1,141,224,400 (£1.14billion). Including the 10.6% administration cost that the government calculates, this rises to £1,262,194,186 (£1.26billion). Housing benefits estimated for this population at £531,440,000 brings their total estimated welfare dependency bill to £1.79billion.
* To the social and economic costs of not freeing people from dependency we must add the child and family work attributed to drug use that was estimated in 2007 to be £1.2billion.

6. THE FUTURE FOR RESIDENTIAL REHAB

Is there a future? Will they be gone?
There is perhaps only one question (in two parts):
A) Given that the government says it is determined to have a treatment system that facilitates people becoming free from dependence as soon as possible, what does it intend to do to stop the disappearance of the very resources, knowledge and skills that know how to provide such opportunities?
B) Why are millions being still being spent on a bureaucratic infrastructure while services that actually transform lives go to the wall?

The Concordat is the depository of knowledge, qualifications and experience in treatment which is proven to get addicts free of all psychoactive substances, sustainably for the long term, and reintegrate them into society in such a way that they wish to give back/make amends for their past.

The Concordat started with over 30 members which are rehabs, as described in this briefing document. These were initially by invitation only but, due to demand to join, more are joining and gaining strength in numbers as well as experience, knowledge and expertise.

The Concordat, apart from a lobby group, will be consultative to educating people about rehab.

A goal for Concordat is to ensure that 25% of people presenting for drug treatment receive rehab as described here as their first choice. This could pick up and help some of the people stuck on methadone scripts with no option.

If excluded from PbR pilots, the Concordat has volunteered to be used as a control group. This is particularly important, given the lack of referrals to rehabs in PbR pilot plans.

The country needs rehabs as much as it needs addicts to quit addiction.