Addiction Today

NO WAY TO DISPENSE PUBLIC MONEY

by Kathy Gyngell
Chair - Prisons and Addictions Forum
Centre for Policy Studies

Read the complete blog here.
Summary below.

The NTA’s poor and unfair practices mean it cannot be trusted. This £19million+ a year public-health authority should be wound down now, not in two years' time.

It is bad enough when we find that huge sums of public money have been wasted, as in the case of the NTA’s management of the last government’s damaging mass methadone prescribing exercise. (The latest UK drug death figures published this week revealed that drug deaths involving methadone rose by another 8% this year and that methadone is now the second highest cause of drugs deaths after heroin and morphine). It is outrageous when we find basic standards of procedure over allocation of capital sums have been ignored.

This appears to be the case with a particularly shoddy process the National Treatment Agency has just overseen. On July 22nd, Drug Action Teams were sent an invitation to bid for £8million of capital – a potential lifeline for rehabilitation centres which have been disinvested in, to the point of closure, over the last 12 years. These are the centres on which the success of government’s new treatment approach will largely depend. But here comes the catch...

They were given less than a week to submit their bids for money on which their survival might depend. In some cases, DATs did not even invite providers to take part in the bidding. The closing date for bids was July 29th so any bids had to be drafted - and the support of one or more statutory bodies to the DAT partnership secured - between July 22nd and July 29th (which included a weekend and was the start of the school summer holiday).

On the basis of the NTA’s past performance, services guiding addicts to drug-free lives would be forgiven for believing that being an abstinence service had a lot to do with their rejection.

For the NTA’s past form on capital allocations does not give comfort. Last time round in the bidding for a capital pot of £54million, the majority of small abstinence rehabilitation providers did not even get a look in, regardless of their track records of getting at least 65% of their clientele totally drug free, into education and training and on the way to employment.  For details of how deeply unsatisfactory this past process was, see Addiction Today’s report at the time.

It is not clear why the Department of Health decided to give this deeply unsatisfactory body a two-year life extension, especially given the Public Accounts Committee’s recent devastating critique. Ministers may come to rue this decision.

The decision has left the NTA operating as usual, with control over spending by Drugs Action Teams and Primary Care Trusts. For both are still required to submit their drugs treatment budget/spending and care plans for approval to the NTA in January 2011. These plans are due to be passed in March, yes by the NTA, for the year to come. This will most likely block any real change till the end of 2012. By then, as one concerned colleague commented to me last week, “no doubt the NTA hierarchy will have embedded themselves in the DH and still be able to destroy and wreck lives by putting whatever spanners in the works of treatment reform they disagree with.”

TIMETABLES FOR NEW GOVERNMENT POLICIES

 

HOME OFFICE 

The HO released its 2010 Drug strategy consultation paper towards the end of August and readers have until end-September to respond.
This is perhaps a once-in-a-lifetime opportunity to get real help for addicts to recover. Feel free to cut-and-paste Addiction Today’s guideline response into the consultation paper. Work will end in December.

MINISTRY OF JUSTICE

The MoJ’s Rehabilitation Revolution aims to establish an offender management system harnessing “the innovation of the private and voluntary sectors, including payment by results, to cut reoffending”.

1- Determine options and strategy:
June-Oct 2010  Develop a Green Paper setting out the approach to reducing reoffending and improving rehabilitation   
Nov 2010-Feb 2011  Consult with the public after publication of the rehabilitation Green Paper   
Mar 2011-Nov 2011  Develop detailed options for rehabilitation in response to consultation.

2 - Trial payment by results mechanisms:
June-Nov 2010  Develop options for contracting out rehabilitation to third parties, including contractors commissioned by the Department for Work and Pensions (offender employment) and Department of Health (alcohol and drug rehabilitation)
Aug 2010  Hold round table with private and voluntary sector providers to refine options  
Aug 2010-Dec 2012  Launch/evaluate a pilot rehabilitation scheme, funded by a Social Impact Bond, to reduce re-offending by paying private-and third-sector providers by results.

DEPARTMENT OF HEALTH

The DoH has five priorities, whose timetables started in June:
o a patient-led NHS
o shift resources to promote better healthcare outcomes including patient-reported outcomes
o revolutionise NHS accountability to patients  - and public; more autonomy for doctors/nurses
o better public health – better access to talking  therapies to reduce long-term NHS costs, and partnering with voluntary and private sectors
o reform social care, promising – at last – that people be treated with dignity and respect.

DRUG DEATHS RISE AGAIN

HEROIN IS BIGGEST KILLER - FOLLOWED BY METHADONE

Drug-related deaths continue to increase, remaining higher than 2001 when the National Treatment Agency for Substance Misuse was founded to reduce them.

Click here for related article on previous years' figures.

UK drug-related deaths rose by 11.8% to 2,182 in a year, reveals the International Centre for Drug Policy at St George’s, University of London, National Programme on Substance Abuse Deaths report. The previous year, it rose 2.7%.

The report – which covers drug-related deaths in 2009 – shows that most of the deaths (1,698 – 77.8%) were men, and most deaths (1,415 – 64.8%) were  people aged 25-44.

“This continuing rise in drug-related deaths is very concerning and shows that we must not waver in our efforts to prevent the loss of life. The effectiveness of both drug abuse prevention and treatment is reflected in the mortality data, so we know we still have a major problem," ICDP director Professor Hamid Ghodse said.

“An immediate impact in reducing drug-related deaths could be achieved by improving the availability of effective treatment and rehabilitation services. However, in the long run, finding primary prevention strategies that work may be crucial if we want to have a major effect on drug-related mortality.

“Each of these deaths is a life wasted, and a family bereaved. Drug abuse is one of the most important social issues of our time, as illicit drugs kill people and destroy families.”

It coincides with another report on drug-related poisoning deaths registered – but not necessarily occurring – in 2009 for England and Wales, unveiled today by the Office for National Statistics. The two reports complement each other, providing a comprehensive description of the extent and nature of deaths caused by drug dependency and misuse.

They are compiled using different geographical and chronological criteria, so show differing results. But this year’s 11th annual np-SAD is the most comprehensive yet, and contains full breakdowns for each UK constituent country as well as the islands. It also follows recent drug death figures from Scotland – released by the General Register Office for Scotland, and again compiled using different parameters – showing a slight reduction in deaths.

Opiates such as heroin, morphine, methadone and opiate analgesics were implicated in most of the deaths, as in previous years. Heroin and morphine alone and with other drugs accounted for 52.9% of deaths. Methadone deaths rose to 23%. Meanwhile, the ONS stated that heroin and morphine deaths in England and Wales (880) were down by 2%, but methadone deaths (408) were up by 8%.

There has been a decline in deaths from stimulants such as cocaine (now 11.4%), amphetamines (2.8%) and ecstasy-type drugs (0.3%). This could be due to increasing use of ‘legal highs’, such as ketamine, piperazines and GHB/GBL, in recent years.

As well as the reports on 2009 deaths, the np-SAD also outlines details of emerging new drugs such as the recently banned mephedrone. Until the end of July 2010, there had been 52 suspected mephedrone-related deaths, although confirmation of most of these is needed.

In addition to the np-SAD report, the ICDP at St George’s today released its annual Volatile Substance Mortality Project report. This includes figures on deaths related to volatile substances – gas, aerosols, glues and other solvents – in 2008. In 2008, there were 36 deaths, down from 59 in 2007.

The report shows a large increase in deaths attributed to helium – although, as an inert gas, it is not strictly a volatile substance. In 2008, there were 25 helium-related deaths, an increase from 10 the previous year.

Click below for details of the ICDP report
Drug-related deaths in the UK Annual Report 2010.

Click below for details of the ONS report
Deaths related to drug poisoning in England and Wales, 2009. 

FROM HOPELESSNESS TO ACTION: MOVING ADDICTS INTO RECOVERY

RESPONSE TO HOME OFFICE DRUGS CONSULTATION

We need ‘saltation’ – a successful leap to the major recovery league, a single mutation which dramatically alters the treatment phenotype, both a quantum jump and a series of rhythmical steps in time. Deirdre Boyd lists system blocks to the country’s recovery – and ‘saltations’.

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In June, prime minister David Cameron stated that “First, there is a problem in our national health service, in that we spend too much time treating the symptoms rather than necessarily dealing with the causes...  Second, all addictions need proper attention, and proper treatment and therapy, to rid people of their addictions, whatever they happen to be.”

In July, he added that “We’ve got to get rid of the centralised bureaucracy that wastes money and undermines morale... If you’ve got an idea to make life better, don’t just think about it – tell us what you want to do and we will try and give you the tools to make this happen”.

So let’s outline some factors which stop people getting “proper attention and proper treatment and therapy” to rid them of their addictions. Then let’s look at broad policy proposals down to a simple suggestion from Addiction Today to add to the jigsaw of recovery solutions.

BLOCKS IN THE CURRENT SYSTEM

For 21 years, the Addiction Recovery Foundation charity – mainly via Addiction Today – has been identifying ways to recover from addiction/dependency and sharing best practice. In more recent years, we have questioned why ‘problematic drug users’ have not been given fair opportunities for recovery: less than 4% of people who turn to statutory services for help to quit drugs actually get a referral to ‘rehab’: rehab/quasi-residential/daycare programmes with a record of creating sustainable recovery (see glossary).

Hansard, which prints all MPs’ speeches in the House of Commons, reported a comment in July by David Burrowes which encapsulates the chaos of the UK’s addiction-treatment system. “The annual report of the National Treatment Agency for Substance Misuse, which was presented to the House... is in stark contrast with the 30th report of the Public Accounts Committee in March, which concluded that £1.2billion is spent on tackling drug misuse without the government knowing the overall effect of that approach.”

If we do get a new drugs policy aiming to get people off drugs and positively transforming their lives, how can it be implemented? With the coalition government, it is not a problem of willingness, but of how its goodwill can be turned into a reality reaching addicts and their families desperate for help.

On top of the sheer logistics of transition from a monolithic failed system to a dynamic inspirational one, implementation must run an obstacle course of vested interests, ignorance and supposedly-neutral civil servants with political allegiances to the last government. For example, Addiction Today has heard rumours of civil servants in the Department of Health stating that rehabilitation is not "treatment" - and that 95% of the treatment budget should be spent on non-rehabilitation, accelerating the downward spiral of failure rather than helping the country towards recovery.

ABOLISH THE NTA

The National Treatment Agency for Substance Misuse has been recognised as the biggest block to getting this country into recovery – Addiction Today was perhaps the first to expose its failings and publicly call for it to be abolished, after attempts to negotiate failed. In July came the first saltation: health secretary Andrew Lansley abolished the NTA.

PROTECTIONISM, OVERPRESCRIBING & LACK OF SOCIAL INPUT IN THE NHS

The NHS has become more not less protectionist, keeping patients within its own control rather than referring them to more clinically-effective and cost-effective rehabilitation specialists. For example, although the NTA trumpets Liverpool as the “city of recovery”, Mersey Care NHS Trust has placed few patients with Sharp or Park View Project, local organisations which enable drug-free goals. Also, Nottinghamshire County Primary Care Trust decommissioned both day and residential services helping people to quit drugs – quoting as justification an out-of-context sentence from the NTA Effectiveness Review.

Add to this a NHS culture of overprescribing addictive legal drugs, and lack of integration with, for example, employment and crime, from funding to outcome measures.

It all points to the necessity of sharing responsibility and power for addiction treatment between not merely the DoH via the NTA but also the Home Office, the Ministry of Justice and Department of Work and Pensions. This leads us to the next saltation...

ADDICTION RECOVERY BOARD

At ARF’s UK/European Symposium on Addictive Disorders in 2009, the idea of an Addiction Recovery Board to replace the NTA was floated to delegates in a policies workshop. It could create policy, manage finance:performance more simply than the current system with less but more key outcome measures, and have a carrot-and-stick inspection system. Also, there is an acute need for more rehab places, which will require higher standards of training across the workforce, which could also come under the remit of an ARB.

The most popular recommendations for an ARB are that it must be less bureaucratic than the NTA, be more transparent and accountable, be able to influence budgets – and run alongside a ‘grievance system’ so that poor commissioning can be exposed and troubleshooting teams sent in to correct it without the current punitive backlashes on providers or patients who make legitimate complaints. Given the number of reports to Addiction Today, this will have to be clear, robust and staffed asap!

The ARB should be backed up by a cross-ministerial committee/council which can feed information to and from ministers in relevant departments such as Health, Home Office, Ministry of Justice, Work & Pensions – even Education, Family, Treasury and Cabinet.

This could also remove the need for reporting of unseemly rows between ministers for control of drug policies, such as on the front page of the Times on 23 August between Theresa May and Iain Duncan Smith.

TREAT ALCOHOL AND ALL DRUGS

Combining policy and funding for both drugs and alcohol treatment should remove artificial barriers and duplicated bureaucracies. Treatment should be offered to people who have problems with any psychoactive addictive drug. Given the proliferation of polydrug use, this also opens the door to tackle cross-addiction, leading to long-term sustainable independence - and independent lives, which can improve their families also.

GREATER NUMBERS NEED HELP

The NTA quotes 330,000 problematic drug users needing help – but its definition covers only heroin and crack cocaine. Add in powder cocaine, marijuana, ketamine, ecstasy, amphetamines and other mind-altering drugs, as well as methadone addiction, and the numbers needing help are recognised as much larger. They will be multiplied when/if people dependent on alcohol and legal drugs such as benzodiazepines are also helped.

ARE THERE ENOUGH REHAB PLACES?

If there are more patients to treat, alongside a move for more patients to be placed in rehabs – residential, quasi-residential or daycare – are there enough places? It is estimated that there might be only about 1,500 residential beds left – and that is available over the year as clients come and go, not at any one time (as a guide, count beds in Addiction Today's Directory).

DRUG/ALCOHOL ACTION TEAMS

A decade ago, Addiction Today forecast that implementing drug policy through D/AATs was doomed to failure; only a handful were competent, and there were no sanctions for poor practices. Today, most D/AATs spend too much of the treatment resources on their own bureaucracy.

And, as financial power sits with Primary Care Trusts, commissioning decisions are dominated by the NHS – a major factor in overprescribing. 

Local commissioners must be free of central bureaucracy, but there must also be safeguards against creating local bureaucracy.  Perhaps responsibility for receiving funds and coordinating local partnerships should rest with local authorities? LAs are the only local public bodies with responsibility across the social policy agenda, and should not have an interest in directing resources into their own structures.

UNBALANCED CONTRACT BIDDING

Harm reduction has a role alongside treatment, but not as a substitute for it. Tier 2/3 organisations offer lower-level services from advice to harm reduction, sometimes therapy – not rehabilitation. But 96-98% of those seeking help to quit drugs are referred to harm-reduction services. When treatment budgets are diverted here, that should be clearly stated: they have different outcomes.

Some tier 2/3 organisations get over 90% of their income from our taxes, via the statutory system. Indeed, just two of these organisations can account for over £100million of our taxes a year. For this, up to 25,000 people could have been treated to rehab annually and be working towards lives independent of drugs and of the state and of our taxes. But the budget for the whole country refers only a third of that number to rehab.
This is a hugely imbalanced system. And those who received such largesse since the NTA was created in 2001 are determined to protect it.

PAYMENT BY RESULTS – IF YOU SURVIVE

Payment by results, or PbR, sounds fair in theory – but risks becoming the most inequitable tool in the new drugs policy. Let’s leave the measures of success – the choosing of which results matter – to one side, as these are being worked on by many groups. It has been suggested that PbR will mean no payment until after results are evidenced – perhaps up to a year later. The small quality rehabs and their like survive on meagre budgets, powered by vocation more than profit. They could not survive six months, far less a year, paying without real-time reimbursement for patients to get well. Only the largest tier 2/3 players enriched in the past decade have the financial reserves.

“It is anxiety provoking to see the potential for vested interests to corner the pooled treatment budget into their own pockets and pretend that the drug problem will be solved by their organisations alone,” one commissioner explained.

“As placements are funded out of social care monies, it will let LAs off the hook and they will bail out of treatment as soon as possible. Payment by results will see off the small independents. Then prices will rise, competition reduce and some ‘one size fits all’ county providers will do for the rest. If the coalition rows back from an integrated locally determined approach, then we’ll be back right where we are, or worse.

"It can be likened to It's A Knockout, with people seeking recovery and those helping them being placed on a slippery pole with more and more obstacles being put between them and the prize of recovery.” 

DEMORALISED STAFF

While rehab staff are under financial pressure due to lack of referrals from the unbalanced treatment system, NHS and other tier 2/3 providers are demoralised due to not seeing clients recover – too many drug workers say they have never seen addicts quit. This has an exponential effect in that, as Project Match proved, more people get better when their therapists believe they will.

A PIECE IN THE JIGSAW OF SOLUTIONS: THE ‘SALTATION’ WEEK

So here’s another Addiction Today “idea to make life better”, as Cameron phrased it. It started when Dr Francis Keaney, vice chair of the Royal College of Psychiatrists and senior lecturer at King’s College London, and Dr Alison Battersby, research secretary and recovery lead of the RCPsych and consultant psychiatrist in Plymouth addiction services, asked how tier-2/3 services could move clients into recovery – and in the face of budget cuts.

This was a time period that we had not previously looked at indepth to identify and share best practice: a period before people reach rehabilitation services, when many staff have given up on drug users’ ability to change. It was a  welcome challenge, showing a shift in thinking towards recovery and collaboration. The idea of a ‘saltation’ week developed from there.

Benefits of the saltation week are as follows.
>> Participants get a thorough assessment – in what other health field are patients given a course of ‘treatment’ without a diagnosis?
>> Assessment and consequent referrals are seen to be transparent, removing heated debates about whether tier 2/3/4/other are appropriate.
>> Appropriate assessment, particularly with Asam patient placement criteria at the end of the week, will identify who can get into recovery with less intensive, less expensive services – without clinical compromise; it is cost- and clinically-effective.
>> The saltation week is a ‘brief’ intervention – yet offers clients more therapy in a week than they currently get in a year on methadone maintenance (see research by David Best).
>> It will propel clients through stages of change, from precontemplation to readiness for action, through Maslow’s hierarchies of need to safety and a sense of belonging; these not only motivate clients into recovery and related services but also reduce dropouts, so services give greater value.
>> If there is a sudden demand for rehab, there might not be enough capacity – so the saltation week will act as a filter, a funnel.
>> For some patients, this intervention might be enough in itself, with no need for more services.
It will also act as a pretreatment week for patients on waiting lists due to lack of capacity, holding participants safely while they await treatment.
>> Ideally, the saltation weeks should be run by people with no financial interest in organisations to which participants might be referred. This could be within the NHS – it might be easier to let go of protectionism if so – run by people such as Keaney and Battersby.
>> On the other hand, if we are not to abolish tier 2/3 services, they could, with a few expert professionals, run such saltation weeks, adding capacity and enhancing services; referrals at the end of the week will need to be independent.
>> If this week were incorporated in tier 2/3 services, it would increase throughput of patients at lower cost – and lead to recovery not same patients maintained on scripts the following year.
>> Just as crucial is staff morale: witnessing positive results of their own work will boost motivation.
>> Payment-by-results: results can be validated as soon as the saltation week is completed.

Read the September issue of Addiction Today for the saltation week programme, details of therapies behind the week, and results of a similar week trialled by Nottingham Community Alcohol Services.

MORE INFORMATION

Download Addiction Today Sept 2010-Saltation and policy

Use this information to fill in the Home Office Drugs Consultation.

WE HAVE ALREADY DECRIMINALISED - THAT'S THE PROBLEM

by Kathy Gyngell
Chair - Centre for Policy Studies' Prisons and Addictions forum

It is hard to understand why Sir Ian Gilmore has chosen, right at the end of his worthy career, to ‘come out’ on behalf of the decriminalisation of drugs as he did in yesterday's Guardian. Even the most intelligent and thoughtful of men can get it wrong sometimes. He certainly has in this case.

How it escaped his attention that we have had a de facto decriminalisation of drugs for the last 10 years in this country, I don't know.

Whether you look at the declining levels of custodial sentencing, the directing of addicts into methadone maintenance, the example of Cambridgeshire police handing out needles rather than enforcing the law, the sanguine response of the judge to Pete Doherty arriving in court with Class A drugs in his pockets, the warnings instead of penalties for cannabis possession albeit now a Class B drug, or the general blind eye turned on the tripling of cocaine use (when was the last time anyone got the maximum 7 years for possession? Now that could be a deterrent) it all adds up to one thing... We do not, in this country, have a coherent, let alone active, policy of enforcement that could possibly be described as ‘blanket prohibition’.

Contrary to an oppressive regime, Sir Ian’s case is based on less than a 10th of prisoners are inside for drug offences and, let’s be under no illusion, some of these are very nasty criminals indeed.

Contrary to received wisdom prison sentences, suspended sentences and fines for personal use and possession of drugs in the Netherlands far exceed those in England – in fact by a factor of about 20. Given that England has one of the highest drug use and the highest problem drug use prevalence rate in Europe – three times higher than the ‘tougher’ not more liberal Netherlands it is more than conceivable that it is the feebleness not the strength of our sanctions that is ineffective and costly.

Anyone labouring under the impression that Portugal’s formal decriminalisation of use and personal possession has been the resounding success it had been sold to be, should think again. An up-to-date analysis of the data on Aids, drugs deaths (overdoses) and the number of homicides related to drugs, as well as of drug consumption, shows them all to have increased since.

Magistrates too, despair of the alternatives left to them, other than custody, when abusive, violent and disorderly poly substance abusers (alcohol is usually in the mix) appear time and again before them.  What would Sir Ian’s solution be to this? Does he really think that removing criminal sanctions for drug use and possession would bring down Aids and HIV?  That it would make addicts’ behaviour less risky, that drug users would user fewer not more drugs, that they would no longer commit crime to feed their habit?  Does he think they would overnight become taxpaying citizens with the resources to pay for private heroin prescriptions – for why on earth should the taxpayer fund this?

The harms caused by de facto decriminalisation are already too high. Decriminalisation would weaken any remnant reason for teenagers, with their increased susceptibility to risk taking, to resist them. It would seriously undermine parents and teachers’ authority.

Professor Neil Mckeganey has cogently argued that current levels of drug use are still relatively low but that the damage caused is disproportionately high. Any further eruption of drug use on a scale comparable to alcohol use, he argues, simply could not be managed, contained or afforded. Hospitals and mental health and child protection services could not cope. Civil society as we know it would be threatened.

Prevention needs to be the order of the day. I cannot see decriminalisation helping that.

Click here for the full article by Kathy Gyngell.

 

CAN THESE LEOPARDS CHANGE THEIR SPOTS?

RESPONSE TO THE NTA BUSINESS PLAN 2010/2011

by
Deirdre Boyd, CEO of the Addiction Recovery Foundation
Kathy Gyngell, chair of the Centre for Policy Studies' Addictions working group

With the  threat of abolition  hanging over its head, the  National Treatment Agency has cleverly extended its longevity by promising to mend its ways. It will, it announced on Friday, use the final two years of  its now-extended life to change the policy it has promulgated over the past nine years.

“We’ve got to get rid of the centralised bureaucracy that wastes money and undermines morale,” prime minister David Cameron stated in July.  But the NTA would seem to have got the last laugh, with over £42.8million of taxpayer‘s money now  allocated to it for two more years to change the disastrous system it created and has so steadfastly defended even in face of the indefensible.   

The NTA will, it promises, help people get off the methadone dependency, tier 2/3 organisation dependency and state dependency which it created via its performance-managed targets.  Its new  Business Plan 2010/11, in a truly Orwellian "four legs bad, two legs good" style, now seemingly advocates the very abstinence approach its spokespeople have repeatedly declared to be unviable.

It will even consult rehabs, the NTA graciously announced – those very rehabs it has ignored for almost a decade and of whose success in getting addicts into drug-free and rewarding recovery Paul Hayes (yes, still the NTA’s CEO) has publicly belittled, scorned or downright denied.  Could it be less than two years ago that  the NTA’s ‘first point-of-contact’ told BBC Home Affairs editor Mark Easton that “rehab doesn’t work”?  (see Comment 5th from bottom here for more derogatory comments from NTA senior managers).

But maybe this was not such a hard promise for the NTA top brass to make, as they look forward to their ‘brobdingnagian’ pension pots in two years’ time. After all, there are fewer rehabs to consult... For under the NTA regime, only 2-4% of addicts seeking help to quit drugs were actually referred to them. The result?  Financial hardship, redundancies, the closure of over 20 specialist rehabs, more wing and bed closures and a loss of the real expertise required to rehabilitate addicts. And with their own personal futures well secured, would success of change be in their interest?

There isn’t any evidence for abstinence or for rehab, they have repeated declared. This is despite two national treatment outcomes surveys - Ntors and Doris - which indicate  strongly to the contrary. It is also in face of experience. As Sir Ian Gilmore said yesterday,  the "absence of evidence" about school milk for under fives is only that; it does not mean that it is not a good thing and has not helped children’s health. All experience suggests it certainly has, he insisted. Similarly with rehab: a joint report in 2008 by the Commission for Social Care Inspectorate with the NTA itself that “residential rehabs outstrip other sectors in every outcome group we measure".

The NTA seems to have bamboozled the Department of Health and a too readily believing government.  For who have they tasked to change their policy and now shift people into ‘recovery’?  Brazenly, it has appointed as one of the duo the addiction psychiatrist most closely associated with the failed medico-clinical treatment approach of the past 20 years years, one of the the proponents and instigators of the last government's failed treating-drugs-with-drugs approach so loved by the NTA, key lobbyist for counterintuitive, expensive and ethically questionable prescribing programmes: John Strang of the National Addiction Centre.

In his capacity as a director of the UKDPC - recipient of millions of charitable funds to, among other briefs, redefine for the nation the notion of (addiction) recovery - Strang chose to use this remit to ensure that any new official definition of recovery excluded full abstinence, ignoring all expert advice to the contrary. 

Nor did he stop there. His UKDPC's plan was to use this new definition of “recovery” to replace real total drug-free outcomes as the measure for the NTA’s Treatment Outomes Profile forms, meaning that their  targets could be easily be hit. Very convenient. For, in one Orwellian sleight of hand, the NTA could claim a recovery outcome when no such thing had been achieved. A reduction in injection frequency would suffice. This would be the basis of NTA’s (aspirationless) claims of treatment success. In face of the derision this deserved, the  NTA has gone on record saying it does not define recovery at all now – despite the fact that “recovery” is the raison d’etre of its Janus-faced Business Plan 2010/2011. That all the goals and actions therein are meaningless can thus be taken as read.

For example, there is apparently no plan to replace the discredited and bureaucratically heavy Top form. It will be forced on ever more people. The NTA states, too, that it has looked at the ASAM patient placement criteria. Yet instead of contacting the creators of this highly-researched method, it plans to reinvent the wheel and spend taxpayer money developing a version for its own purposes. It also plans to spend more taxpayer money on a mutual aid directory. Yet this is already provided free by Addiction Today. Under Championing abstinence-focussed treatment in the business plan... well, for further help interpreting  the Business Plan’s double speak, read our glossary.

It is, however, commendable that Dr David Best, who has wriiten so cogently and expertly on abstinence-based recovery in the pages of Addiction Today and other professional journals, has been appointed as the other half of the recovery duo.  We wish him the very  best of luck in counterbalancing his former mentors, and getting them on the true road to recovery with a Damascene conversion. They should heed him, for he is the only person giving this exercise any credibility.

As David Cameron said in June,“There is a problem in our national health service, in that we spend too much time treating the symptoms rather than necessarily dealing with the causes... All addictions need proper attention, and proper treatment and therapy, to rid people of their addictions”.

We really would love to believe, as he and many in government must wish to believe, that we will witness the NTA's respecting the trust that has been placed in it and seeking the rehab expertise that actually helps people to get off life-destroying drugs and rebuild their lives and their families’ lives. But the serious worry is that this initiative for change get will be lost in adherence to disinformation and blowback, and submerged in intransigent ideology about the non-recoverability from addiction. Of even more concern, will its lack of understanding continue to marginalise the expertise necessary to help the 330,000 or so addicts desperate for the sobriety which is the basis for them to get back, or get for the first time, their self esteem and their lives?

We will be happy to be proved wrong. But we are not holding our breath.

A GLOSSARY FOR OUR TIMES

REWRITING THE DICTIONARY

Tickboxers could eradicate war, disease, poverty and addiction in a mere few strokes of the pen, to meet targets – by rewriting the dictionary. Deirdre Boyd offers a glossary to recent claims.

Preview from the September 2010 Addiction Today journal.

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In a sci-fi story, an apparatchik from earth arrives to tell the spaceship crew they would not recognise home. “We have got rid of war, disease, poverty,” he explained – we could add “addiction”.
“When did this happen?” asked the captain.
“When we rewrote the dictionary,” the apparatchik responded.

So how have today’s apparatchiks rewritten the dictionary to give a semblance of success? The words below –  from the government’s National Treatment Agency for Substance Misuse – are given a meaning perceived by people generally. This is followed by the ‘target on paper’ definition, or Top, set in the NTA context.

Problematic drug user. Someone whose drug use causes a problem for them or others.
Top definition: someone who uses heroin or crack cocaine; only these make you eligible for ‘treatment’, only these are counted in targets.

PDU.  A dehumanising word for a problematic drug user. 
Top definition: a statistic.

Legal drugs. These include addictive drugs which can destroy lives, such as benzodiazepines; kill more people in the UK than illegal drugs - click here for details.
Top definition: does not come under definition of a PDU, so does not count towards targets, so you are ineligible for treatment/funding.

Alcohol/alcoholism.  See “legal drugs”.

Treatment. The general public thinks that this means addicts and people with drug problems get help to become drug free and rebuild lives.
Top definition: someone somewhere made an appointment for you and got your name on file.

Retention/retained in treatment. Patient given consistent proactive therapy and other support to become drug free and reclaim life.
Top definition: patient is seen at one appointment, can be given a second appointment 12 weeks later (during which some died or were imprisoned), defined as hitting target of 12 weeks’ retention.

Rehab. More rigorously researched than NTA preferments, also proven to be the most successful in getting people off drugs long term. Also help people overcome methadone addiction. “Residential rehabs outstrip other sectors in every outcome group we measure,” concluded a government CSCI report.
Top definition: something to find a less-effective alternative to; over 20 closed under our regime. Click here for some details.

Balancing the treatment system. The need to balance a failed system created by the NTA where only 2-4% of patients manage to get to rehab, and a similar number to become drug free.
Top definition: aim of ARF and Recovery Group UK;  copying phrase in NTA Business Plan 2010/2011 blurs NTA role in creating such imbalance.

Dependency.  Another word for addiction, a “dysregulation of the mesolimbic dopamine system” or brain-chemical disorder, as opposed to misusing drugs through choice. Diagnosing between dependency and misuse is vital as each requires different care.
Top definition: “We don’t define dependency, just as we don’t define recovery,” stated NTA senior managers – which means targets in the NTA Annual Reports submitted to parliament are meaningless.
(2): drug users become dependent on state drugs and handouts due to lack of appropriate care.
(3): providers are dependent on NTA for referral revenue, cannot whistle-blow.

Free from dependency. The general public thinks that this means patients have been helped to quit drugs, are rebuilding their lives.
Top definition: patient stopped using main drug briefly, uses other drugs; patient is kept dependent on prescribing organisations for decades.

Recovery.  First mention I found is in a book copyrighted 1954 to Alcoholics Anonymous and means quitting alcohol/other drugs, living in such a way as to stay stopped, repairing relationships and making amends for any wrongs done.
Top definition: “We do not define recovery” (see dependency); plus UKDPC redefinition as “control over drug use” – eg, control over using exactly nine grams of cocaine every day.

Prescribing. If used, should be for brief detox and/or stabilise patients, but drugs such as methadone are more addictive and harder to withdraw from than even heroin.
Top definition: “treatment”.

Harm reduction. Aims to reduce harm from drug use, addresses fallout not the cause.
Top definition: “treatment”.

Detox/ification. Getting toxic substances out of the body, such as the ancient romans vomiting so they could continue orgies of food and drink.Should be immediately followed by treatment so people do not relapse as the ancient romans did.
Top definition: “treatment”, “rehab”, “abstinence”, “successfully leaving treatment”.

Retox. Put patients back on drugs instead of giving recovery treatment after detox.
Top definition: recommended in papers by John Strang due to number of patients dying after detox at Maudsley clinic where he works; Strang is co-heading the NTA Business Plan 2010-2011.

Patient placement criteria. Created by the American Society of Addiction Medicine to give the most fitting type(s) of care to people with drug problems, in the most clinically- and cost-effective ways – click here.
Top definition: “[UK] criteria are based on failure,” NTA CEO Paul Hayes said this year; not the ASAM criteria, something to be created.

Top. Targets on paper; an unverified page of boxes to tick to show ‘treatment’ results, which omits legal addictive drugs and other outcomes which quality rehabs offer, including treating worse cases.
Top definition: Treatment Outcomes Profile, used by the NTA as official data for UK statistics.

Drug deaths. Something the NTA was set up to reduce, have instead increased under its regime.
Top definition: "drug deaths have reduced" - click here for facts.

Ideologists. Top definition: people who question us.

MARIJUANA LEGALISATION'S UNINTENDED CONSEQUENCES

Next November, Californians will ballot on allowing people 21 years and older to possess, cultivate and transport cannabis for personal use, as well as enable its commercial production and sale. Professor Keith Humphreys of Stanford University School of Medicine's psychiatry and behavioural sciences departments, discusses the potential consequences.

He recently returned to Stanford after a one-year stint in the White House as a senior adviser on national drug control policy - and was a key speaker at the UK/European Symposium on Addictive Disorders in London last May.

Click here to watch the video.
You can also read excerpts below.

Click here for related facts, also CannabisSkunk Support. 

Q: There are estimates that, with legalisation, marijuana use could rise 50-100 percent%. Are those projections reasonable?

Humphreys: We know very well from other commodities that if you make something illegal, the price of it goes up. And when you make it legal, it becomes much cheaper. So the findings are credible. Why they’re scary is that big drops in price tend to affect mainly people with less disposable income... teenagers, the unemployed, other people who have just a small amount of extra money. This will drop marijuana to something they could easily afford to do on a daily basis.

It is not just legalising consumption; it is legalising production. That means you're going to have an industry, like the tobacco industry, that will have lobbyists and marketers and lots of money. In fact, I wonder if tobacco companies might go into this business. They are well-positioned. They have the outlets and the pricing power. It will become a mass-produced, very cheap product.

Q: But the proposition also allows people to grow their own marijuana...

Humphreys: For the vast majority of people, if there's a refined product in a nice package down at the store that costs 1/10th as much, and you don't have to water or worry about sunlight, then they will buy it.

Q: What about the argument that taxing marijuana will provide much-needed revenue?

Humphreys: We should be legalising child pornography and human trafficking? There's lots of awful things that raise money, and that doesn't make them right. The second point is that taxes never recoup the harm from substances. If you look at all estimates of alcohol and tobacco taxation, it never even touched a fifth of the amount of health damage. So you get a little money in the short term, but in the long term, someone's got to pay for car accidents and kids flunking out of school and things like that.

Q: What about the notion that by legalising it you take it out of clandestine operations?

Humphreys: You will probably get rid of some gun violence, for example. But look at the example of a tobacco company. You could have substantially more death. There's lots of ways to do violence in this world. You can weaken government regulations in a way that results in thousands of people dying.

In terms of its medical use, I have compassion for patients; I was a hospice worker for many years. But I don't feel that's the typical person getting medical marijuana. A paper in the Harm Reduction Journal that profiled about 4,000 such people said the prototypical patient was a 30-year-old male who had been smoking pot for about 15 years and wasn't seriously ill - that group is riding on our compassion for the people who have Aids, MS or cancer.

To me, it's a pretty big jump to go from saying that this plant has some medical value, to saying that its consumption — and also its production and advertising — should be legalised.

STAGES OF CHANGE

A BLUEPRINT TO BUILD STRONG FOUNDATIONS FOR CHANGE

Professor Carlo DiClemente’s Stages of Change model is feted worldwide for enhancing the understanding and skills which make a substance-abuse treatment provider effective. It helps clinicians develop thoughtful, individually tailored, scientifically grounded treatment plans – here he extends it to policy and programmes.

This article was originally published in Addiction Today journal, March 2005. As we prepare for new - and hopefully more progressive - policies to address addiction treatment, this information is increasingly relevant.

Research tells us that central qualities of the effective clinician are empathy, warmth and positive regard. It also tells us that developing and implementing a clearly articulated treatment plan and providing treatment for the problems a client presents are effective skills. But putting these qualities and skills into action is a challenge.

How does an individual clinician learn to express these central human qualities of caring and compassion with clients who are often difficult and unhappy about being in treatment, and whose central disorder is often characterised by behaviours which do not easily elicit empathy? And given the incredible heterogeneity among substance-use clients, how can a clinician develop a personalised treatment plan grounded in science?

Further, how can we apply those same principles to other workers in the field of substance-use treatment, including members of drug/alcohol action teams? Is there a common framework? Can the process of change be applied at a systemic level as well as at an individual level?

We answered these questions at ARF's UK/European Symposium on Addictive Disorders in London (where photo on this page was taken). But let’s open up the issue... Deepening our understanding of addiction can also deepen our understanding of the implications for policy and programmes. It can let us see that we need a common framework – such as Models of Care – and a common assessment tool, which has eluded drug/alcohol action teams, to their increasingly vocal  frustration. Deep understanding of what our clients are all about, and the meaning of what we are doing, can lead us to a conceptualisation of the entire process of change and the entire continuum of care.

WHAT IS THE STAGES OF CHANGE MODEL?

Developing genuine understanding of – even empathy for – a client requires professionals to look beyond that client’s behaviour when using alcohol or drugs, and to understand the nature of substance-use disorders and difficulties inherent in changing long-standing, pervasive patterns of thought and behaviour. They are helped in this by the ‘stages of change’ model, combined with a good treatment plan.

The current model posits five stages of change:
o precontemplation
o contemplation
o preparation
o action and
o maintenance.

People in the first stage show no sign of intent to change a problem behaviour, be it because of a lack of awareness, unwillingness or a lack of hope because previous attempts failed. Contemplators are more visibly distressed about their problem behaviours than precontemplators and have begun to weigh the positives and negatives of change.

The preparation stage covers people who are ready to change both attitude and behaviour, and to change soon. When people are in the action stage, behaviour change has clearly begun. So they need skills to implement specific change methods. They also need to be aware of the psychological – cognitive, behavioural and emotional – events which can work against their best efforts. And they need to learn how to prevent major reversals, such as having a relapse and returning to pre-change patterns. The action stage lasts an average of about six months.

The last major stage of change is maintenance, where people sustain and strengthen improvements they have made. They can take a few years to feel “secure”.

_____________________________________________

“The stages of change are a model of ‘how to think’
rather than ‘how to do’...
They describe attitudes, intentions and behaviours
related to tasks of change”

_____________________________________________

All of this is voluntary rather than coerced change. Indeed, the stages of change are a model of “how to think” rather than “how to do”. They describe attitudes, intentions and behaviours related to the tasks of change. Note that the “change” sought is specific: commitment to change one behaviour might say nothing about commitment to change a related behaviour. And each stage refers to a time period and to tasks which a person or organisation must complete before moving to the next stage.

COMMON CHARACTERISTICS

Let’s look at the commonalities of clients in the five stages of change – then readers can draw their own conclusions as to the similarities at a systemic level for change in our field.

The common characteristics of people in the precontemplative stage are: defensive, resistant to suggestion of problems associated with their use/ behaviour, uncommitted or passive in treatment/work, consciously or unconsciously avoiding steps to change their behaviour, lacking awareness of a problem, often pressured by others to change, feeling coerced and ‘put upon’ by significant others.

The characteristics of contemplators of change are: seeking to evaluate and understand their actions, distressed, desirous of exerting control or mastery, thinking about making change, have not begun taking action and are not yet prepared to do so, many previous attempts to change, evaluating pros and cons of their behaviour and of changing it.

Now we come to the preparation stage, where people: intend to change their behaviour, are ready to change attitude and behaviour, are on the verge of taking action, are engaged in the change process, are prepared to make firm commitments to follow through on the action option they choose, and are making or have made the decision to change.

Common characteristics of people in the action stage are that they have: decided to change, verbalised or otherwise shown a firm commitment to change, tried to modify behaviour and/or environment, demonstrated motivation, and are willing to follow suggested strategies and activities for change.

And what do we share at the maintenance stage? Characteristics are: working to sustain changes achieved to date, focusing considerable attention on avoiding slips or relapses, feeling fear or anxiety about relapse and facing high-risk situations, and less frequent but often intense temptations to return to old habits.

MOTIVATIONAL STRATEGIES to promote change include giving advice, practising empathy, removing barriers, providing feedback, providing choice, clarifying goals, decreasing desirability of unhealthy habits, and active helping.

CLINICAL STRATEGIES for people in the action stage include maintaining engagement in the change process/treatment, supporting a realistic view of change through small successive steps, acknowledging the difficulties, helping people to identify high-risk situations through a functional analysis and developing coping strategies to overcome these, helping people to find new reinforcers of positive change, and helping people to assess if they have strong support networks.

Clinical strategies for people in the maintenance stage include helping them to identify and sample drug-free sources of satisfaction, supporting lifestyle changes, affirming people’s resolve and self-efficacy, helping them to practise and apply new coping strategies to avoid a return to unhealthy habits, and maintaining supportive contact.

TREATMENT/ACTION PLANNING

Based on information gathered during assessment, this is created in collaboration with each person wishing to change and addresses mutually agreed goals. It serves a variety of purposes, including prioritising short- and long-term goals, choosing the optimal interventions for specific goals, identifying barriers to the achievement of goals, and monitoring progress towards goals over time.

For our new purposes, goals can be as much on a national or local level as they can be on a personal level. They can include decrease in or cessation of substance use, which can impact on other goals such as improving family and employment situations, extending social support networks, and returning to school or college. One obvious benefit of prioritising goals is that attention is focused on the most pressing problems.

Another is that successes in these main areas often place people in a better position to address secondary goals.

It is important to recognise the treatment/action plan as flexible and changeable. Unexpected needs or problems can arise. Some goals might depend on others. Some might take longer than anticipated.
Common features of treatment plans include:
o developed as a result of a comprehensive assessment and modified over time as warranted
o reflects participation from appropriate disciplines –  medicine, psychiatry, psychology, social work or vocational rehabilitation – as warranted
o reflects the person’s presenting needs and specifies  their strengths and limitations
o consists of specific goals which pertain to the attainment, maintenance and/or re-establishment of physical and emotional health
o identifies specific objectives which relate directly to the treatment/change goals
o specifies the frequency of treatment/change contacts
o includes provisions for periodic re-evaluations and revisions, as needed, of the plan, and
o identifies criteria for determining if goals have been achieved, as well as for terminating change.

Some qualities of well-formed treatment/change goals are that they are: salient and meaningful to the person or organisation wishing change, incremental and so more manageable, concrete, specific and behaviour focused, able to increase desired behaviours, realistic and achievable, seen as requiring work and effort, and are appropriate for the projected change period.

FUTURE DIRECTIONS

In addition to its popularity with many addiction counsellors and researchers, the stages of change model should prove useful in tracking and predicting change. Most people have followed problematic paths over many years and made multiple attempts to change before being successful. They get stuck at certain points in the process of change and invest more time and energy in not changing than in activities to promote change. There is an ebb and flow, and important, distinct tasks which mark the process.

People can move forward and backward through the stages, and they can do so quickly. Their tasks involve a number of dimensions – motivation, decision making, efficacy, coping activities – which have an ongoing influence on the change process, can be accomplished quickly or slowly, and can be done more or less completely. These stages of change seem to resemble the stage dimensions of personality development proposed by Erickson in 1963.

Moving through change does not appear to be a case of doing more of the same thing, but instead doing the right thing at the right time. There is also a growing body of literature which appears to support the relationship of stages to important outcomes.

One advantages of model is that the process of change is assumed to be the same for substance-abuse problems as well as other life problems. It has been applied to changes related to many behaviours, including anxiety, medication compliance and health protection. The stages cover considerable ground, since the process of intentional behaviour change is central in the life of an individual, with major implications for growth and development.

There are few models which can be applied to such a variety of behaviours with such consistent results... Let’s change together.

PROFESSOR CARLO DiCLEMENTE PhD is internationally recognised as co-creator, with Dr James Prochaska, of the Transtheoretical Model of Change, which identifies stages of change and other factors that predict treatment outcomes and allows many more people to enter treatment programmes at earlier stages of readiness.
He is the author of many scientific articles, and co-author of Changing for Good, The Transtheoretical Model, Substance Abuse Treatment and the Stages of Change, Group Treatment for Substance Abuse: A Stages of Change Therapy Manual and Addiction and Change: How Addictions Develop and Addicted People Recover.
For 20 years, he has led research in health and addictive behaviours including Project Match, the world’s most exhaustive research into the impact of alcohol treatment.
Research interests include smoking, substance abuse treatment, dual diagnosis, early intervention with problem drinkers, pregnancy smoking cessation, and initiation of health-protection/health- threatening behaviours.
He is professor and chair at the Psychology Department, University of Maryland.

BECOME AN INTERNATIONAL INTERVENTIONIST

Training dates:  15,16,17 Ocober 2010
Location:  central London
Subsidised rate: £300 for the three days' training
Trainers:  Southworth Associates and Intervention 911
with the Addiction Recovery Foundation (charity no 328133),
organiser of UKESAD and publisher of Addiction Today journal

REHABS: MEET PRIVATE-PAY REFERRERS
While your staff train, they meet more interventionists who can refer clients to your recovery facility.

THERAPISTS: GET A SECOND STRING TO YOUR BOW
* Addiction therapists and counsellors can learn more skills to guide the most reluctant substance and behavioural addicts into optimal treatment.
* In these times of redundancy, counsellors can soar on a second career as an interventionist.

Trainer 1: John Southworth refers more clients in a year than could fill all the rehab beds in the UK. Click here for more details.

Trainer 2: Ken Seeley is founder of Intervention 911 and starred in A&E's Interventions TV series. Click here for details of 911 and here for videos of Ken.

Organiser: Deirdre Boyd. Deirdre (pictured with John above) is CEO of the Addiction Recovery Foundation, editor of Addiction Today and organiser of UKESAD. She is known as a champion of organisations and professionals helping vulnerable people into recovery from addiction.

DON'T MISS OUT - PLACES STRICTLY LIMITED
First come, first served - first paid, first guaranteed reserved place
Email Deirdre@addictiontoday.org

MORE INFO...
* Earn CEUs towards becoming a Board Registered Interventionist
* Training will use Johnson Model components
* Opportunity to join the International Association of Intervention Specialists. Email Deirdre@addictiontoday.org

NUTRITION: REPAIR YOUR BODY IN RECOVERY

This article from Addiction Today journal will be posted on this webpage by the end of July 2010.

OPEN LETTER TO PROFESSOR STEVEN FIELD

CHAIR OF COUNCIL - ROYAL COLLEGE OF GPs
14 Princes Gate
Hyde Park
London SW7 1PU

Dear Professor Field,

GP OVERPRESCRIBING OF ADDICTIVE DRUGS

I am writing to you regarding serious concerns I and many others have about the widespread iatrogenic benzodiazepine and z drug addiction which has existed in the UK over the last 50 years. I am writing as an ex-involuntary addict and as someone who has researched this subject from its beginnings in the 1960s when Valium addiction was becoming a problem.

I was prescribed Ativan in 1975 for anxiety and in hindsight I realise that I became addicted in a matter of weeks.  I wanted to discontinue Ativan but could not because of the horrific withdrawal symptoms; successive GP' surgeries then continued prescribing it for the next 35 years, mostly on repeat prescriptions without the need to see a doctor, as none of them had the knowledge to help me discontinue.

They were not even able to suggest a basic diazepam tapering schedule including an equivalents table to calculate how much diazepam to switch over to or any knowledge of the type, severity or duration of the withdrawal symptoms.

I finally found withdrawal information on the internet and managed to discontinue this year, after 14 months, using the diazepam taper method recommended in Professor Heather Ashton’s manual Benzodiazepines: How they work and how to withdraw. This took over a year and I used support and advice available from The Council for Information on Tranquillisers and Antidepressants in Liverpool and the Bristol and District Tranquilliser Project as none of my past GPs could offer help and their only advice was "do it slowly". These charitable organisations were started in the 1980s to offer support and advice to people wanting to discontinue addictive prescription drugs. The physical and psychological withdrawal symptoms have been crippling; I am still very unwell and am worried whether I will ever completely recover from the damage inflicted by these drugs.
 
I have since found many people similar to me who have been made seriously ill as a result of taking benzodiazepines; their stories of suffering are harrowing. They all say that withdrawing from benzodiazepines has been the most destructive and devastating experience in their lives.

I am not writing to discuss my own individual case but to express my and others concerns regarding this serious issue in the UK.

Media research points to a figure of 1.5million people currently dependent upon benzodiazepines and z-drugs in the UK; about 180 per surgery. I have been corresponding with the Dept of Health, the MHRA and the Commons and Lords with regard to these issues. It is through this correspondence and my research that I am becoming aware of the part that GPs’ prescribing habits, lack of training and ignorance of numerous Department of Health guidelines issued since 1980, have been responsible for this national scandal continuing for so long.

The health system has created this problem but does not appear to wish to treat it. It seems no-one is accepting responsibility.

I note from the RCGP’s website that:
"The Royal College of General Practitioners is the professional membership body for family doctors in the UK and abroad. We are committed to improving patient care, clinical standards and GP training."

Problems with addiction to benzodiazepines were emerging in the 1960s and various guidelines have been issued to GPs since, the main ones being:
The Committee on Review of Medicines report in 1980; the Committee on Safety in Medicines publication in 1988; the Mental Health National Service Framework (NSF) guidelines in 1994 and their publication in 1999; the Dept of Health publication in 1999; NICE’s publication in 2004 and the Chief Medical Officer’s update 37 also in 2004.

All these stated that "benzodiazepines should be prescribed for just two to four weeks for relief of severe or disabling anxiety or severe or disabling insomnia in patients who are extremely distressed".

Doctors have largely ignored these guidelines and prescriptions for benzodiazepines are on the increase.

Diazepam prescriptions are up 11% this year. In 2007 Dept of Health statistics show that there were 11.5 million prescriptions for benzodiazepines, 5.5 million for z drugs and a third of these were for 56 tablets or more suggesting large numbers of patients on long-term treatment; 852,000 of these were for lorazepam which is one of the most problematic and 10 times the strength of diazepam.

If the RCGP is committed to patient care, clinical standards and GP training, why hasn’t it made efforts to ensure that its members read important drug safety guidelines and put them into practice? Many doctors are obviously out of their depth and need guidance. They have created the problem by creating and sustaining addictions but do not know how to rectify the problem.

The Department of Health’s review of policy on addiction to prescription drugs and OTC medication has already been in progress for 12 months. The report itself is now scheduled for the end of 2010 with policy discussions to take place into 2011. What role has the RCGP played in this review? Also, in the interim period, will you be sending advice to GPs to avoid new addictions? Also, what plans does the RCGP have to deal with current ones?

I now refer to the transcription below from your interview on ITV West last year:

‘Professor Steven Field, Chair of the Royal College of General Practitioners, said:
“We now try to prescribe (benzodiazepines) only for a few days because we know that it's very difficult to get people off these drugs, but there are still a lot of people on benzodiazepines and tranquilisers that have been on for many years…..the patient doesn't want to come off the drug because they've tried before and they get all of these horrible withdrawal side effects which are very similar to coming off heroin or cocaine and indeed in my experience it can be more difficult to get people off benzodiazepines.

"What we’ve got to try to do is work with the patient to bring them off very slowly and very gradually, but the best thing to do is to not prescribe them in the first place…..some of the drugs, in some people, it can be three or four days of the drug before they get hooked. And what you find is that they can't have a day without them. They start to get very anxious, very sweaty, very panicky. In others it's even worse - it's not just that they can't do a day without them they need two or three or more, to actually keep them calm. So each patient is very different. Bringing people off the drug is very different and you have to do it slowly and really tailor it to the patient.”
(ITV West interview, March 09)’

This information has been known since Professors Lader, Tyrer and Einarson’s work in 1979/80 and the Committee on Review of Medicine’s investigation into benzodiazepine withdrawal symptoms in 1980. Why hasn’t the RCGP acted on this information?

It is not similar to coming off heroin as you state in your interview. This is a common mistake that GPs make. You cannot come off them using willpower and this is poor and dangerous medical advice. What medical and scientific advice was this based on? Heroin withdrawal can take as little as a week; benzodiazepine withdrawal can take months or years and many people are still suffering withdrawal symptoms after 2 years or more.

Most GPs do not recognise these symptoms as lasting more than two months. It is common practice to then misdiagnose them for re-emergence of the original symptoms or development of new ones; these are then frequently treated by dosage increase or additional medication making eventual withdrawal even more difficult. Some patients have also been advised to discontinue too abruptly or forced by the withdrawal of prescriptions to ‘go cold turkey’, causing seizures and protracted withdrawal symptoms lasting years. Protracted withdrawal symptoms have also been largely denied by the medical profession against overwhelming evidence from patients and scientific evidence to the contrary.

I am informed by the Dept of Health that NHS Clinical Knowledge Summaries ‘benzodiazepines and z drug withdrawal’, largely based on Professor Ashton’s work, is available online for GPs’ guidance; neither my last nor current surgery were aware of this when ‘managing’ my withdrawal. It is the duty of the RCGP taken to ensure doctors read and implement guidelines.

There has also been endless concern about benzodiazepine addiction covered by countless television documentaries eg Panorama, Brass Tacks, the Cook Report, and newspaper articles and concerns raised by MPs, academics and the public. What justification has the RCGP had for taking no action in the face of 30 years of widespread public concern?

I will now refer to your comments in the Sunday Telegraph:

‘Sunday Telegraph May 2nd 2010 - Prescriptions of Valium, the highly addictive pill for stress and anxiety disorders, have risen by more than 11% in three years. Senior doctors expressed alarm that the drug diazepam, commonly known as Valium, is now being dispensed almost 5 million times a year in England. The Royal College of General Practitioners said GPs should be referring those suffering from anxiety for counselling, not drugs which could result in a lifelong addiction.

"They warned that the pills, once dubbed "mother's little helpers", were very difficult to stop taking, and should no longer be recommended to most patients.

"NHS figures show that in the first nine months of 2009, more than 3.6 million prescriptions were written for diazepam in England – an 11% rise on the 3.25 million dispensed in 2006, and an increase of 17% in a decade. If the trend continues, it will amount to more than 4.8 million prescriptions issued in 2009, according to figures held by the NHS Prescription Pricing Authority. The drug can be given for stress and anxiety but GPs are told to only allow its short-term use, and are encouraged to refer patients for counselling, or in some cases to prescribe antidepressants. Prof Steve Field, chairman of the RCGP said he was "shocked" by the figures uncovered by The Sunday Telegraph.’

I find the statement that you, as Professor and Chairman of the RCGP was shocked, shocking to me.  If I, as a lay person, can trace the problem through from the 1960s then surely you, as chair of the RCGP and an eminent professor and practicing GP, can too.

I find the statement that you are ‘shocked’ after 40 years of blindingly obvious evidence surreal. Do you read Dept of Health statistics or guidelines or the British Medical Journal or newspapers? Do you not watch television? Again, the writing was on the wall in the 1960s and the evidence there to see from the late 1970s; to express shock in 2010 is an insult to those affected.

Again, I ask why the RCGP has not played a helpful role or accepted some responsibility for causing and sustaining addiction in the UK.

People addicted to prescription drugs also say they regard themselves as involuntary addicts because they depended on their doctors; these drugs were taken in good faith from someone in a position of trust. When I asked to be referred for emotional support my doctor ticked the category ‘substance misuse’. I followed the advice of a succession of doctors to the letter, so I can only deduce that if addiction to prescribed drugs is construed as ‘misuse’ then all my doctors from 1975 to date should be arrested and charged with drug dealing.

The only real help for people has come in the form of Professor Ashton’s manual and charitable organisations that provide vital help-lines. The RCGP has, as far as I am aware, provided no research, no guidance for GPs, no training for GPs and no help for patients. Why not?

I note from looking at the itinery for the RCGP Annual Primary Care Conference 7-9 October 2010 at Harrogate that there is nothing on benzodiazepine dependency; neither was there anything last year.  Evidently, therefore, despite being shocked you do not consider this warrants discussion.

No-one so far has apologised to the patients; would the RCGP like to apologise for all the suffering caused by its members over a 40-year period?

Finally, I am writing this letter to request that the RCGP address this problem as a matter of urgency and to ask you to tell me what action you will be taking to rectify the damage done and ensure that all existing involuntary addicts are offered the help they deserve.

Yours sincerely

John Perrott
Lancaster

HEALTH SECRETARY: NTA TO BE ABOLISHED

Health secretary Andrew Lansley announced today that bureaucracy will be cut as health "arm's length bodies" are reduced from 18 to 8-10, saving over £180m by 2014/15 - and one of the bodies to be abolished is the National Treatment Agency for Substance Misuse.

The White Paper, Equity and Excellence: Liberating the NHS, assessed whether the work of each body was essential, being duplicated or could be better carried out by a different body. Subject to parliamentary approval, organisations no longer needed will be removed from the sector, with essential work moved to other bodies. This process part of the cross-government strategy to increase accountability and transparency, and to reduce the number and cost of quangos.

"Over the years the sector has grown to the point where overlap between organisations and duplication of effort have produced a needless bureaucratic web," Lansley explained.

The Department will work with each organisation affected by the changes over the next few months to help them through the transition process.  The form of this work will vary according to the nature and scale of the change for each organisation.

Abolished*:

Alcohol Education and Research Council
National Treatment Agency for Substance Misuse - functions to be transferred to the new Public Health Service

Retained, with changes*:

Care Quality Commission
National Institute for Health and Clinical Excellence

* For more details, click here

ABOLISH NTA TO CUT DRUG ADDICTION

"Methadone prescriptions for heroin addicts would be cut and the National Treatment Agency that runs the programme scrapped under plans from the Tories favourite think-tank," reports Rosemary Bennett, social affairs correspondent of The Times newspaper.

"The Centre for Social Justice, set up by Iain Duncan Smith, the Work and Pensions Secretary, said it was unacceptable that only 4% of addicts in treatment ever get “clean” and accused the agency of “pushing aside” proper rehabilitation. The Times has also learnt that the highly influential think-tank will use a report on Monday to throw its weight behind Ken Clarke, the Justice Secretary, who called for short prison sentences to be scrapped.The report will state that the CSJ agrees with him that short sentences of two months do nothing to help to rehabilitate offenders and should be replaced by community orders."

The CSJ's Green Paper on Criminal Justice and Addiction comes as the government considers major changes to drug policy and the future of the National Treatment Agency. Set up in 2001, the NTA oversees the controversial “harm reduction” strategy - most recent NTA treatment statistics show that of the 207,000 addicts a year who use 'treatment' services, only 8,980 completed their treatment drug free.4,600 addicts have access to residential rehabilitation.Numerous residential drug rehabilitation centres have closed because of lack of patients, despite no sharp fall in the number of addicts.

The CSJ said that the NTA, the running costs of which have spiralled to £18million a year, merely processes addicts with a “fatalistic” belief that they can never get clean. It wants it scrapped and replaced by an Addiction Recovery Board, chaired by a minister and charged with getting addicts off drugs altogether, using the best local private sector and charity programmes, or “recovery communities”.

The report says there is a role for methadone, but it should be used only as part of a wider treatment programme, with abstinence the goal.

"There is no strategy or incentive to reduce the numbers on maintenance treatment and move people into recovery," the CSJ said. The report is also highly critical of how drug use is tolerated in prison: 55% of prisoners received into custody each year are classified as problematic drug users. According to the Ministry of Justice, one in five men who reports using mainstream drugs first used them in prison.

DRUGS FIGURES PAINT INCORRECT PICTURE OF MISUSE

MULTIPLE DRUG USE NOW THE NORM,
HEROIN SHUNNED BY YOUNG

Government drug policy is too centred on heroin abuse, fails to take account of the realities of current usage trends and needs to focus on individual user behaviour if it is to reflect the true picture and formulate meaningful responses, a leading academic at National University of Ireland Maynooth urged.

 

A Dizzying Array of Substances; An Ethnographic Study of Drug Use in the Canal Communities is the result of a long-term study which closely examined the realities of drug use in local life of Rialto, Bluebell and Inchicore, three communities served by the Canal Communities Local Drugs Task Force. It was led by principal investigator Dr A Jamie Saris and primary field researcher Fiona O’Reilly at the Department of Anthropology, NUI Maynooth.

The ethnographic research, carried out mostly in 2008 and early 2009, gives the most compelling evidence to date that multiple drug use is the norm amongst drug users in the Canal Communities and, the researchers concluded, most probably in other areas.

“The big problem is that as far as government is concerned, ‘drugs’, from a treatment perspective, has traditionally meant heroin.  Thus, the apparent leveling off of the need for a very opiate-centric treatment service in the Canal Communities in recent years is deceptive” said Dr Saris.

Besides the ethnographic work, the study surveyed, on a long term basis, 92 people using either heroin or methadone in the study area.  Unsurprisingly most of those surveyed were on methadone (98%).  Of those surveyed:

•63% claimed to have used heroin in the previous three months
•30% had used crack cocaine
•22% had used powder cocaine
•46% had also taken street tranquilisers
•50% were on prescribed tranquillisers, and
•60% had also smoked cannabis within the past three months.

“The majority of those registered on the methadone treatment programme are also using a cocktail of other substances, very often including heroin.  Multiple drug use is the reality for nearly all users, and official policy needs to have this understanding at its centre”, Saris said.

In the course of their study, the research team also noted a strong stigma against heroin use amongst the 16-25 age group who still regularly used a lot of other substances, including cocaine and off-label prescription medication.  “The reality is that these people are difficult for a treatment infrastructure built around opiates to service.  If they have issues, they are more difficult to address,” said Saris.

" The stress that policy-makers and community activists place on ‘crack’ or ‘heroin’ or any other single drug as clear and present social dangers obscures the ubiquity of polydrug use. It makes it appear that these users are very different from other drug-users in the rest of society including cannabis and recreational cocaine users, and it also obscures how commonly legal pharmaceuticals, such as benzodiazepines, even methadone itself, are regularly consumed ‘illegally’.”

He said that a focus on drug use alone is the mistake. “The lives we examined, however damaged by an attraction to certain pharmaceuticals, are rarely defined solely by such behaviour. These people are also sons and daughters, fathers and mothers, partners and lovers, as well as employees and community members.  This sensibility does in fact inform a lot of local community activities aimed at assisting users, but such work is often difficult to justify to official funders under the rubric of ‘treatment’, as currently understood.  Unless we can understand who users are, what they are taking and why, we will not be able to assign the appropriate resources, treatments or management systems.”

Tony MacCarthaigh, chairperson of the Canal Communities Local Drugs Task Force commented that “individuals and not chemicals need to become the focal point of treatment, and treatment needs to assist individuals in developing another orientation not just to drugs, but to life". 

BOOKKEEPER/ACCOUNTANT WANTED

TO WORK AT THE
ADDICTION RECOVERY FOUNDATION,
PUBLISHER OF ADDICTION TODAY

charity no 328133

Details: Download Job specification-ARF Bookkeeper

Bookkeeper/accountant wanted to work 1-2 days/week

Location: London SW1

£32,000 pro rata
inc London weighting

Must be proficient in QuickBooks,
have experience/qualifications to deliver
monthly management accounts
and bring books to profit&loss stage
working with charity's Treasurer and CEO.

Being in recovery is desirable but not essential.

Please email your CV to:
info@addictiontoday.org

Equal opportunities employer

PCT FACES HIGH COURT CHALLENGE

AFTER AXING ALCOHOL REHAB FUNDING

A campaign group dedicated to securing effective abstinence treatment for the UK’s 1.1m alcohol dependents today launched a High Court challenge against a Primary Health Care Trust after it axed all funding for places at one of the country’s leading rehabilitation centres. This PCT also axed funding for places at a day programme which helped alcoholics to recover.

Lawyers for UK Advocates wrote threatening proceedings against Nottinghamshire County PCT in the Administrative Division of the High Court after learning of the health authority’s plan to stop all referrals to the Priory Clinic in Nottingham from the end of September this year.

Central to UKA’s challenge is the PCT’s use of a single sentence from the National Treatment Agency's 2006 Review of the Effectiveness of Treatment for Alcohol Problems as evidence to justify denying county residents access to detoxification beds, residential rehabilitation places and aftercare programmes provided at the clinic.

MISREPRESENTED RESEARCH

In a letter to referral agencies, seen by UKA and Addiction Today, the PCT uses that one quote from the NTA's Review questioning the effectiveness of residential rehabs that base treatment programmes partly on the 12 Steps of Alcoholics Anonymous.

However, on being informed of the use of the 212-page report in this context by the Addiction Recovery Foundation, the authors of the quote - Duncan Raistrick and Nick Heather -  responded that they "are very unhappy that the Effectiveness Review might have been misrepresented" and that the report found that "there is a place... for residential care… for those with greater impairments particularly with regard to social deterioration and high risk of relapse" and "we are supportive of mutual aid, including 12-step programmes and of Twelve Step Facilitation".

SPURNING DoH GUIDELINES

Nottingham PCT's letter makes no reference to a series of definitive guidelines from the Department of Health that commissioners of alcohol treatment services are expected to follow when making decisions on the shape of NHS alcohol treatment services, and that make it clear that both residential rehabilitation and 12-step based treatments should be included in a range of treatment interventions.

It also pre-empts forthcoming guidance from the National Institute of Clinical Excellence (NICE) on the management and treatment of alcohol dependency, expected early next year.

The PCT’s decision comes amidst deepening concern among service providers and users over the future of alcohol treatment in the county, which are currently ’under review’.

Earlier this year UKA threatened similar action against Nottinghamshire County PCT when it abruptly pulled funding for an intensive day care programme for alcohol dependents in the city commissioned from a private sector provider, despite highly promising early results.

UKA chairman Robert Beckett said: “I’ve spent over 20 years trying to work in cooperation with NHS commissioners to secure the rights of alcohol dependents to treatment that gives them the best possible chance of getting sober and staying sober. Sadly this has failed and we have no option but to ask the courts to intervene. The PCT has cherry picked one sentence from one of scores of academic studies - some of which have very different findings - to justify doing this, even though it runs contrary to the Department of Health guidelines they are committed to following.

"This is serious blow for alcohol dependents in Nottinghamshire and will have a huge knock on effect on thousands of people either in need of treatment or already in recovery through the clinic.

“We are caught in an epidemic in alcohol dependency that is killing thousands every year and costing the country billions of pounds, yet the PCT is prepared to stop providing a service that has been proven to be outstandingly successful for 20 years.

“We hear similar stories about inadequate and poorly structured services elsewhere in the UK all the time and this action could be just the first of many.”

References:
Review of the effectiveness of treatment for alcohol problems (Raistrick et all, 2006)
Models of Care for Alcohol Misusers, (National Treatment Agency, 2006)
Alcohol Misuse Interventions: Guidance on developing a local programme of improvement (DoH, 2005)
Signs for Improvement - commissioning interventions to reduce alcohol related harm (NTA, 2006)

NTA EVADES DEFINITIONS

IN FRAMEWORK FOR UK

The National Treatment Agency for Substance Misuse plans to roll out a “new framework document” for the country. Addiction Today will not reveal details in advance – but is already concerned about accountability and outcomes.

The draft framework document starts with its central point: “The NTA will  promote vision that recovery from dependency is the foundation of all commissioning and service delivery”.

Sounds promising.  But Addiction Recovery Foundation CEO Deirdre Boyd (editor of Addiction Today) asked NTA director of delivery Rosanna O’Connor and central head of delivery Colin Bradbury how the NTA defined “dependency” given that its past use of this word did not conform to DSM-IV or ICD10, the two most widely used diagnostic tools in the world. Bradbury replied that “We do not define dependency, just as we do not define recovery”.

So... the framework for the country is based on: “The NTA will promote vision that [undefined] from [undefined] is the foundation of all commissioning and service delivery”.

TARGETS

So when the NTA claims to get people "free of dependency" in its annual report to parliament and in Guardian advertorial... this has no definition, going by Bradbury and O'Connor's statement.

EXCLUDING THIRD SECTOR AND REHABS?

The next line in the NTA document adds “... both in the community and prison setting”. Boyd asked about the omission of the third-sector, rehabs/quasi-residential/daycare/sessional work, long dedicated to recovery. O’Connor answered that these providers were included under “community”, denying that the word excluded these, as it has traditionally done.

NTA CEO Paul Hayes contradicted this at a southwest regional meeting, disparaging rehabs/voluntary organisations’ outcomes versus community services. For clarification, Boyd requested a script of this speech. The NTA denied it existed, then had to admit Hayes spoke from written notes – which remain unavailable. However, she did have a meeting with O'Connor who said "community" meant any service outside prison, then agreed with Hayes and repeatedly contrasted community and rehabs/similar.

This nation deserves better.  Undefined targets mean nothing is accountable – and the general public will again be misled into thinking the NTA is promising ‘normal’ definitions (eg, clinical definition of recovery from dependency).

UK drugs policy must be implemented by a body trusted by the field and by government, with transparency, accountability, effectiveness and goodwill. Will the country get that?

PATIENT PLACEMENT CRITERIA:

SELECTING APPROPRIATE TREATMENT

About 50 million lives are in the hands of companies across the globe which state that they use ASAM ‘patient placement criteria’ to authorise addiction treatment. What are these criteria? And how can they help give happier results for more people when there is also a need to cut spending?

Perhaps the Addiction Recovery Foundation was before its time... When the National Treatment Agency for Substance Misuse was created, this charity asked in vain for a common assessment tool for patients/clients. Professionals needed a proven quality aid for their work, patients needed to be diagnosed correctly and placed in appropriate care paths, and researchers needed commonalities of measurement. Such an assessment and referral tool is the tried-and-tested Patient Placement Criteria developed by the American Society of Addiction Medicine.

With a new drugs policy due soon, we highlight why the PPC should be integral.

[LATE ADDITION:  in August 2010, the NTA released its Business Plan 2010/2011 and mentioned Patient Placement Criteria - we would be glad it has at last taken up our suggestion but for the fact that it intends to rewrite these proven criteria... plus ca change...]

Print-friendly version:
Download Addiction Today 125-Patient Placement Criteria

What ingredients make these Patient Placement Criteria so effective?

Four features characterise them:

1. 1. comprehensive, individualised treatment planning
2. 2. ready access to services
3. 3. attention to multiple treatment needs, and
4. 4. ongoing reassessment/modification of the plan.

Four important missions underlie them:

1. enable patients to receive the most appropriate and highest-quality treatment services
2. encourage the development of a continuum of comprehensive care
3. promote effective, efficient use of care resources
4. help protect access to and funding for care.

Correctly applied and implemented, the Asam criteria can assist patients in accessing a much broader continuum of care and menu of services than is typically available.

As to research, the Asam criteria are the most intensively studied set of addiction placement criteria. A considerable body of work exists on them, including at least nine evaluations involving 3,641 subjects.

RESEARCH BEHIND THE CRITERIA

Agencies – including the National Institute on Drug Abuse, the National Institute on Alcohol Abuse and Alcoholism and the Center for Substance Abuse Treatment – have invested over $7million in research on PPC. Several controlled studies found that treatment based on PPC are linked to less morbidity, better client functioning, and more efficient service utilisation than mismatched treatment. At the end of this article, there are details of where to find references and more information.

USES OF PLACEMENT CRITERIA

Asam criteria provide a multidimensional assessment structure, initially to generate a service plan which leads to appropriate placement, then a formal treatment plan which meets the patient’s assessed needs and improves the prospects for a positive outcome once in treatment. They are intended to enhance the efficient use of limited resources, increase patient retention in treatment, improve outcome and prevent relapse. Thus they advocate for individualised, assessment-driven treatment and the flexible use of a broad continuum of care.

The criteria also offer a nomenclature and guidelines to describe an expanded set of treatment options and promote the use of a wider continuum of services.

Increasingly, however, treatment must be driven not only by assessment but by the outcome of treatment measured in real time. No single treatment is appropriate for all people at all times. So matching treatment settings, interventions and services to each individual’s particular problems and needs is critical to his or her success in returning to productive functioning in the family, workplace and society.

Measurement during treatment that tracks real-time outcomes and the quality of the patient’s engagement and therapeutic alliance allows for modification of the strategies and level of care depending on patient progress – or lack of it.

MATCHING FOR SUCCESS

The six assessment ‘dimensions’ of patient placement criteria are outlined in the PDF at the top of this page, which can be downloaded for view.

To engage the patient in a collaborative therapeutic alliance, the assessment is in the service of what the patient wants – such as “get my children back”. It identifies obstacles and resources, liabilities and strengths in each of the assessment dimensions: this table is also in the PDF.

The criteria are as objective, measurable and quantifiable as possible. They are ‘scored’ numerically – and this helps to remove subjective heat or arguments from decisions. Some PPC aspects do need subjective interpretation – but that is no different from biomedical or psychiatric conditions in which diagnosis/assessment/treatment are a mix of objectively measured criteria and clinical judgment.

GOALS OF TREATMENT

The goals of intervention and treatment – including safe and comfortable detoxification, motivational enhancement to accept the need for recovery, the attainment of skills to maintain abstinence, and the like – determine the methods, intensity, frequency and types of services provided.

The decision to prescribe a type of service and subsequent discharge of a patient from a level of care is based on how that treatment and its duration will influence resolution of the dysfunction and improve the patient’s prognosis. So the treatment might extend beyond resolution of observable symptoms to the achievement of overall healthier functioning, the difference between abstinence alone and recovery. The patient demonstrates a response to treatment through new insights, attitudes and behaviours.

Addiction treatment programmes have as their goal not simply stabilising a patient’s condition but altering the course of the patient’s substance-use disorder and overall functioning.

INDIVIDUALISED TREATMENT PLAN

Treatment should be tailored to the needs of each patient and guided by an individualised treatment plan developed in collaboration with the patient. Such a plan should be based on the patient’s goals for treatment, a comprehensive biopsychosocial assessment of the patient and, when possible, a comprehensive evaluation of the family. The treatment plan should list:

• problems prioritised by obstacles to treatment and risks and arranged according to severity – such as obstacles to recovery, knowledge or skill deficits, dysfunction or loss
• strengths – such as readiness to change, a positive social support system and a strong connection to a source of spiritual support
• goals – a statement to guide realistic, achievable, short-term resolution or reduction of the problems
• methods or strategies – treatment services to be provided, site of those services, staff responsible for delivering treatment
• a timetable for follow-through with the treatment plan, which promotes accountability.

The plan should be written to facilitate measurement of progress.

PROGRESS THROUGH LEVELS OF CARE

As a patient moves through treatment in any level of care, his or her progress in all six dimensions should be continually assessed to ensure that treatment is addressing changing needs. Certain problems and priorities are thus identified as justifying admission to a particular level of care. The resolution of those problems and priorities determines when a patient can be treated at a different level of care or discharged from treatment.

Should a patient drink or use drugs during treatment, the immediate response should be to revise the treatment plan rather than automatically change the level of care or administratively discharge the patient.
Also, some funders might require that a patient be “motivated for sobriety” as a requirement for admission to a programme. Given the characteristic symptoms of denial and lack of readiness to change in addiction disorders, the only requirement should be that the patient is willing to enter treatment. Clinicians then facilitate the patient’s self-change process along the stages of change.

CHANGE TO A CULTURE OF SUCCESS

Effective implementation of the Asam patient placement criteria will require a shift in thinking toward outcomes-driven case planning.

A variety of agencies will need to make this shift, including regulatory agencies, purchasers of services, clinical and medical staff including throughout the NHS, and referral sources such as courts, probation officers, child protective services and employers.

The patient placement criteria offer a system to improve patient-centred, comprehensive care through multidimensional assessment and treatment planning that permits more objective evaluation of patient outcomes. With improved outcome analysis driving treatment decisions, the problems of access to care and funding of treatment can be championed more effectively.

MORE INFORMATION

Applying Asam Placement Criteria DVD & manual (10 CE hrs) by David Mee-Lee and Kathyleen M Tomlin - order from www.hazelden.org
Asam101: Basics on Understanding and Using Asam Patient Placement Criteria, 2nd edition is a 3-hour online course at www.dlcas.com/course59.html
Asam Patient Placement Criteria: implications for assessment and treatment of patients with co-occurring disorders - read at www.changecompanies.net/assets/pdfs/ArticleASAM.pdf
Level of Care Index (LOCI-2R): Checklist tool listing criteria to aid in decision-making and documentation of placement  +  Dimensional Assessment for Patient Placement Engagement and Recovery (DAPPER): Severity ratings in the six Asam PPC-2R dimensions.   To order: www.changecompanies.net
For clinical questions or statistical information about the instruments, contact Norman Hoffmann PhD at evinceassessment@aol.com.
 
Article by Deirdre Boyd, from documents supplied by Asam PPC author David Mee-Lee.

TREATMENT ‘MATCHING’ EVOLVES

Matching patients to treatment services has evolved through at least four approaches.

Complications-driven treatment gives cursory attention to the diagnosis of a substance-use disorder. Rather than actively treating the primary alcohol or other drug disorder causing a patient’s symptoms, only secondary complications or sequelae are addressed. For example, gastritis is controlled, depression is medicated, fractures are splinted – but care for the addictive disorder is superficial or nonexistent.

Diagnosis, programme-driven treatment, in contrast, recognises the substance-use disorder but diagnosis alone drives the treatment plan. For example, by policy, a diagnosis of substance abuse might assign someone to outpatient treatment, of substance dependence to inpatient treatment, without regard to a patient’s ‘service needs’. Patients are assigned fixed lengths of stay in static approaches, often in response to a mandated referral, policy guidelines or available funding.

Individual, assessment-driven treatment  – assessment, treatment matching, level of care placement, and progress evaluation through assessment – is an ideal approach to care. Its multidimensional assessment identifies and prioritises problems in the context of the patient’s severity of illness, interference with treatment or recovery and level of functioning. Treatment services are matched to the patient’s needs over a continuum of care. Ongoing assessment of progress and treatment response influence future treatment recommendations.

Outcomes-driven treatment, the most recent approach, adds measurement of outcomes in real time. The focus on “during-treatment” feedback of outcomes, patient engagement and therapeutic alliance allows real-time modification of the treatment plan. Tracking the most salient outcomes and measures of alliance and patient engagement inform decisions about which problems should be prioritised and what changes made in strategies and level of care.

CORRECTING THE MEDIA

COMMENT FROM PROFESSOR NEIL McKEGANEY
on Drug Dealing and Communities

"As a result of an article that initially appeared in the Scotsman newspaper, a number of media outlets reported that I have proposed that drug dealers and drug dealing can have a number of positive impacts on communities.

I would like to make it clear that the report in which that view is set out was a summary of the Joseph Rowntree Foundation drugs research programme(1). Within that report it was noted that one of the research studies undertaken by researchers at Kings College had outlined their finding (not mine) that drug dealing could have some positive impacts on communities. It is misleading of sections of the media to present that view as being my own.

It would have been quite wrong, in summarising the Joseph Rowntree Foundation research, only to have included those views and those findings with which I personally concurred. Indeed, it is the responsibility of science to be dispassionate in relation to the evidence and to report findings irrespective of the likely reaction to those findings.

In terms of my own views on drug dealing and drug related matters more broadly, these are set out in the book Controversies in Drugs Policy and Practice which will be published by Palgrave later this year.

Finally, if we are to understand the impact of drug dealing on communities, it is important that the media and others do not demand of researchers that they only report those findings which dovetail with their preferred views. To do that would be to profoundly weaken the capacity of science to deepen our understanding of these and other social problems." 
 
Neil McKeganey
Professor of Drug Misuse Research
University of Glasgow

(1) Charlie Lloyd and Neil McKeganey (2010) Drugs Research: An Overview of Evidence and Questions for Policy. Joseph Rowntree Foundation

THE HEROIN TRIAL FAILURE

by Anders Ulstein

Read the full article here. Summary below.
Read related article: Dodgy dossier 2. 

 

The Lancet report (29 May 2010) of a recent heroin prescription trial has been widely promoted as a success. But only five out of 43 clients - who received a 450 mg of legal heroin twice a day plus a nightly oral methadone supplement over a 26 week period - managed to get off street heroin.

The remaining 38 decreased their consumption of street heroin while on the legal stuff but are still involved in the illegal heroin market, still involved in the crime, harm and misery related to it.

Regardless of the results, the authors make the following recommendation based on their study: "UK Government proposals should be rolled out to support the positive response that can be achieved with heroin maintenance treatment for previously unresponsive chronic heroin addicts." 

What is a significan and surprise finding is that, even when offering free heroin, the programme has such a limited impact on the use of street heroin. And it is far costlier than rehab - up to five patients could go to rehab with a possibility of becoming drug free for the cost of each one still on drugs and with unchanged lifestyles in the Riott trial.

The cost of heroin prescription per client is estimated to be about €18.000 a year, far more than for other treatment options. The UK government has spent about €700,000 on two heroin trials last year.

MISLEADING MEDIA REPORTS

Even Reuters fell victim to the prescribers' interpretation. "Prescribing heroin to addicts who can't kick their habit helps them stay off street drugs, British researchers said Friday", under the headline "Prescription heroin helps addicts off street drugs". This is misleading. 

Associated Press reports that "Some heroin addicts who got the drug under medical supervision had a better chance of kicking the habit than those who got methadone, a new study says", under the title "Study: heroin better than methadone to kick habit".

First of all, to "kick the habit" means to get off the addiction. The aim of the trial was not to get people off addiction, and it did not even measure that. Second, the study does not say that heroin is better than methadone, it suggests that for some hard to treat clients (5-10% of the heroin addicts) heroin might give better results.

To see such inacurate and misleading reporting by the world's two most serious news agencies should worry everyone who is interested in how science is translated.

What this trial illustrates is the limitations of such harm reduction measures rather than its strengths. It also illustrates how scientific results may be distorted and misleading, possibly intentionally.

The researchers display a profound lack of understanding of what addiction is. The report's lead author Johon Strang says the results shows they have "turned around" the users' drug problem. What is in fact "turned around" is a small piece of the symptoms of addiction in a small group of people. The drug problem is not turned around and certainly not the addiction.

REFERENCE 

The study is called Supervised injectable heroin or injectable methadone versus optimised oral methadone as treatment for chronic heroin addicts in England after persistent failure in orthodox treatment (RIOTT): a randomised trial, written by John Strang and collegues.

Addiction Today's earlier comment: Dodgy dossier 2.

"ADDICTIONS AND RECOVERY"

SELF HELP FOR ADDICTS, FAMILIES, FRIENDS

The Addiction Recovery Foundation has updated and republished this book by its CEO Deirdre Boyd, and kept it at a low price of $9.99, to help as many people as possible to recover from addiction/ dependency and to support those who live around them.  This book can also be given by therapists to clients and families.

All royalties go to the charity (reg no 328133) to support its work.

Read excerpts and buy this invaluable guide here. 

  

WHAT REVIEWERS HAVE TO SAY:

“Read this book to find out about the techniques of recovery
that can guide you in the dark moments of your addiction.
Read this book to recognise that in the journey of recovery,
who you are, and what you have been,
is not the same as who you can become”
Professor Neil McKeganey
Director: Centre for Drug Misuse Research, University of Glasgow

“Recovery is a miraculous story
and this book provides an insight into some everyday miracles
and replicable successes”
Dr David Best
Chair: Scottish Recovery Consortium

“Never was there more need for the self-help tactics and peer support
which Deirdre Boyd sets out so logically, honestly and compassionately 
in her book”
Kathy Gyngell
Chair: Centre for Policy Studies - Prisons and Addictions forum

THE 'SCIENTIFIC CITIZEN'

THE DANGER OF UNQUESTIONING 'TRUST'

by Kathy Gyngell

Read the full article here. Summary below.

 

Was anyone else more than a little disturbed by Professor Martin Rees' call in his Reith Lecture for public policy choices "to be leveraged  by 'scientific citizens'?

His impossible quest for consensus in interpreting scientific evidence to enable government to correctly manage future risk and uncertainty on our behalf, risks a science/ state symbiosis as unhealthy as that between religion and the state of the past.

The idea of scientific citizens tasked with stamping brand 'trust' on science whilst mediating what we think is the last thing we need just now.

 In case he hadn't noticed, scientific citizens already abound demanding deference to the authority of science, whatever the dimensions of the topic in question.  Last month's launch of the International Centre for Science in Drugs Policy marked a new development. Its mission to build a network of scientists "to speak out about evidence based drugs policy", played up scientists as victims of a state of scientific evidence repression and suppression. But in fact all that the non sequitur boiled down to was a disapprobation of law enforcement in the name of science; an arbitrary characterisation of the focus of 'today's drug policy efforts' which excluded any mention of 20 years of investment in 'harm reduction' goals, to which  policy failure can equally be attributed.

 Bertha Madras, professor of Psychobiology at Harvard Medical School's Department of Psychiatry, is also concerned with science in drug policy. Yet her conclusion - that 'prevention with drug control policies involving parents must be the first line of defence' - could not differ more from theirs.   

... Then there is the recent promotion of narrowly 'correct' results of a small, though expensive, trial of experimental heroin prescribing published recently in The Lancet. The authors' conclusions suggest that it is scientists' reason, more than technical 'error', that needs questioning.

This trial demonstrated that medically prescribed heroin resulted in a statistically significant decrease in street heroin use by the heroin addicts given it (over those medically prescribed injectable methadone and oral methadone). As a result the authors have confidently advised government to "roll out" proposals "to support the positive response that can be achieved with heroin maintenance treatment for previously unresponsive chronic heroin addicts".

The results should hardly come as a surprise - the heroin to which they were addicted didn't involve stealing for and was dispensed twice day in a friendly caring environment.

 This was a poor outcome for the already low threshold of success set by the research design.  Only one eighth of patients, just 5 in all, of the 43 in question, became 'abstinent' from street or illicit heroin despite  a heroin dosage of 450mg twice a day plus a nightly oral methadone supplement over a  26 week period (not abstinent as we would understand the term - only from illicit heroin, nor from crack, alcohol or cannabis). 

No amount of complex logical regressions or statistical dressing up make this marginal response to a combination of free, safe handouts and psycho-social care (the contribution of which is not assessed) something that could in future justify such expensive use of scarce health resources.

UKESAD 2010: VIDEO HIGHLIGHTS

"UKESAD 2010 was an inspiration," writes InExcess TV founder and presenter George Williams who filmed the three-day international symposium Building Bridges: from addiction to recovery.

"Our highlights capture its spirit, with clips from key presentations and interviews, including White House drugs adviser Keith Humphreys, as well as news and views from delegates and exhibitors. Intervention was a major theme this year, and we talked to some of the world’s most respected practitioners".
Click here for memories and highlights.

Watch out for full interviews to be aired over June and July, starting with...

White House drugs adviser and Stanford University professor Keith Humphreys opened this year’s Plenary - along with David Burrowes MP, Baroness Massey, John Southworth and Ken Seeley - with an incisive presentation on the fundamental changes arising from President Obama’s healthcare reforms and the new National Drug Control Strategy.

The US reforms will extend access to healthcare services to an extra 30million people - see also the Addiction Today May 2010 issue for hardcopy details.
Click here to listen to Humphreys' inside knowledge.

UKESAD 2010 gave the opportunity to catch up with international interventionist John Southworth. With both personal and professional experiences in the field of substance abuse and mental health for over 40 years, he uses his experience and knowledge to assist individuals and families through their own personal struggles. Talking openly and honestly with his own unique style he explains to George Williams the role of intervention. He has learned that addiction can be fatal if the appropriate education and steps to recovery are not taken. Click here to learn more about life-saving education.

 

"STOP THE TOP": NTA RESPONSE... VS THE EVIDENCE

Dr Jason Luty revealed research in the March 2010 issue of Addiction Today showing that the National Treatment Agency’s Top Treatment Outcome Profile form is “criminally invalid”. The NTA’s Colin Bradbury gives his defence below - and Addiction Today editor Deirdre Boyd balances the scales by laying out some of the facts ascertaining the validity of NTA claims. Would readers sum up the cases with a verdict of “fit for purpose” or “criminally invalid”?

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"All the research evidence states that drug treatment is effective in reducing drug use and cutting crime," writes Bradbury, head of delivery for the National Treatment Agency for Substance Misuse. "This is clear from the National Treatment Outcomes Research Study – Ntors – in 2001 through to the Drug Treatment Outcomes Research Study – Dtors – in 2009. The purpose of the Treatment Outcomes Profile – Top – was not to supplement or second-guess this national body of knowledge, but to enable local clinicians to assess the progress of individual clients against their own care plan in the course of a treatment programme."

"There are so many inaccuracies and diversions in Colin Bradbury’s defence of Top and the NTA delivery that it is hard to constrain the corrections in one page. But, for transparency, let’s try," writes Boyd, editor of Addiction Today and CEO of the Addiction Recovery Foundation.

"The statement that Top should not supplement Ntors or Dtors is irrelevant to our case. But it does remind me of a grave distortion in both these surveys: that the outcomes of detoxification are mixed up with those from ‘rehabs’ or residential rehabilitation.  For the uninitiated, detox is merely purging the body temporarily of chemicals, like the ancient romans deliberately vomiting so that they could continue their orgies of eating and drinking. In good practice, patients are referred into treatment after detox. Such treatment can be rehab or other treatment indicated by a care plan.  So detox is not treatment.

"Yet both Ntors and Dtors confused the outcomes of detox with rehab, for reasons still to be satisfactorily explained. Clearly, when comparing this joint-outcome with methadone maintenance – the other option in Ntors – the gaps in outcomes were artificially narrowed.

"However, Ntors at least acknowledges that the most difficult, chronic cases went to rehab; Top is incapable of such diagnostic recognition.

Bradbury does go on to say that Top should “enable local clinicians to assess the progress of individual clients against their own care plan in the course of a treatment programme”. This it emphatically does not do... “The NTA continues to collect more and more statistics in order to hide the truth,” one hard-pressed CEO emailed me. “Year on year for the past five years, our agency – an abstinence based rehabilitation project – receives more calls from those suffering with addictive disorders and families stating that they have been told that rehab is not an option by their local Drug Action Teams. They cannot get help. They report that they are simply assessed, assessed and assessed again. Great for gathering statistics but poor service for people.”

Kathy Gyngell writes more on Ntors and Dtors in the May issue of Addiction Today.

REVIEW BY PEERS

Bradbury: The National Treatment Agency started developing this 20-item outcomes tool in 2006 and it was subsequently validated in the peer-reviewed journal Addiction. Top covers outcomes for the four key domains set out in national care planning guidance: drug use, injecting risk behaviour, crime and health, and social functioning.

Boyd: Let’s put to one side that the authors of the ‘peer review’ of Top included its own author, paid by the NTA in the first instance to produce it almost overnight – after all, if you cannot sing your own praises, who will?
The key question here is: what was it reviewed to be capable of? “Peer reviewed as fit for purpose,” the NTA proclaimed in 2008 in a taxpayer-funded PR programme. The trusting might think that “fit for purpose” means effectiveness in implementing Bradbury’s earlier statement. Perhaps that Top asks the best questions to monitor/feedback client progress? That Top questions elicit top clinical feedback? No... the review was not about that. Rather, it confirmed that the Top questions  are “fit for purpose” to elicit “reliable” rather than ambiguous responses.
Here it should be noted that Top is a self-report form without independent audit.  

LANCET PUBLICATION

Bradbury: As a by-product of this local process, Top does give us an extra insight into how treatment is delivered. National Top data submitted so far is already having a significant impact in increasing the international knowledge base of the effectiveness of treatment. For example, Top outcomes data for over 14,000 individuals with heroin and crack cocaine problems was published by The Lancet in a paper last autumn.

Boyd: The erroneous data published in the Lancet – written by NTA employees rather than independent reviewers, with “abstinence” meaning from only one drug not all drugs, for only a short time, in an approach costing 4-6 times more than some rehabs – can be found by clicking here. Where is the compliance to the hippocratic oath of “first do no harm”?

CRIME QUESTIONS

Bradbury: The stakeholder group which advised the NTA in the development of Top was always aware that crime questions in an outcomes tool designed for clinical use would be contentious. However, the NTA consulted with the British Medical Association, the General Medical Council, and the Department of Health’s Digital Policy Unit, responsible for protecting the confidentiality of patient records. All approved the crime items on the Top. Agreed minutes of these meetings are published on the NTA website.
The four items that are concerned with crime were carefully constructed and tested with over 1,000 clients in the process that was eventually published in Addiction, and was shown to be eminently workable in practice.

Boyd:  Dr Jason Luty covered this in the March issue of Addiction Today.  Dr David Best also published research showing how figures are massaged - for details, click here. One treatment provider CEO confirms his experience of what Best’s research states. “Bradbury misses the point re honest answering of Top forms. There is a vested interest in being dishonest.  Admitting to increased drug use or crime can result in consequences – being taken off methadone or told that they are not motivated and thus not ready for rehab. He comments on the relationship between clinician and service user. These forms act as a barrier as opposed to improving the therapeutic relationship. The forms contribute to the ‘sausage factory’ experience as opposed to real individualised care, listening and support offered in a therapeutic relationship.”

TOP DEPLETES RESOURCES

Boyd: "Bradbury states that this tool was to enable local clinicians to assess progress. So an audit ought to be undertaken asking local clinicians if it is helping to assess progress,” one typically aggrieved treatment-centre CEO wrote to me. “It certainly does not assist our agency in assessing progress. It wastes time that could be spent doing worthwhile activity with service users. The only local clinicians who speak up for it are those whose funding depends on keeping Drug Action Teams and the NTA happy as opposed to their service users. Dare I suggest that these agencies are well skilled in massaging figures.”
Other organisations have had to hire extra admin staff to administer the Top form, so that precious resources are drained from their core work of helping patients to recover.
“We have to fill in over 1,000 Top forms on a regular basis,” said one NHS clinical director. “It costs us money. That might not be so bad if only Top fed back some useful information to us which could help our patients and our procedures. It does not give us any data.”

ASKING QUESTIONS

Bradbury: Dr Luty claimed that his audit of the Top showed “patients are simply not answering the questions properly”. I would suggest that instead of blaming his patients for not answering questions properly, Dr Luty should consider whether the questions around crime – and all other domains – are being asked in a sensitive and appropriate way.
The NTA has always stressed that no client should be forced to give information that they do not wish to. However, if an individual tells a clinician two pieces of information which are obviously contradictory – for example, that they are not working or committing crime, but are spending £900 a month on drugs – then this should be explored further.
The fact that an individual does not feel able to tell the truth is important clinical information and should not be glossed over.
In cases where a client persists in giving contradictory information such as this, the NTA’s guidance is clear: rather than submitting obviously false information, “Not Answered” should be entered for the appropriate Top item.

Boyd: This is already addressed under the heading of Crime Questions. 

WHAT OUTCOME MEASURES?

Bradbury: A recent Ipsos Mori opinion poll disclosed that the public’s chief expectation of drug treatment is that it should reduce crime and antisocial behaviour in their area. There is already a significant body of evidence to say that drug treatment helps reduce acquisitive crime.
Even if Addiction Today got its wish to “stop the Top,” any national outcome measure will inevitably rely on the clinician and client having an honest and open conversation on what is happening in that individual’s life.
Given the tough public spending decisions that lie ahead, I would suggest that unless the treatment field is able to demonstrate its worth in delivering meaningful outcomes for both the client and the community (including a crime-reduction dividend), then the unprecedented increases in funding that have been forthcoming in the past few years may well be at jeopardy. We know that the public expect nothing less.

Boyd: To address this crisis, Addiction Today/the Addiction Recovery Foundation is working with a select number of think-tanks to create valid outcome measures. We have been offering our expertise and time free of charge - a fraction of the £20million feeding into the NTA annually.
I leave the last word to another reader:  “I hope that, when Colin Bradbury makes threats about the field demonstrating its worth, he includes the NTA. The easiest way to save money without affecting outcomes is to disband this counterproductive, expensive quango.”

GOVERNMENTS, POLICIES AND MANIFESTOS

“Government policies can improve drug problems – or worsen them,”  White House drugs adviser Keith Humphreys notes. As Obama releases his first US drugs policy this summer, and three contenders for the next UK government publish their manifestos, it is timely for Deirdre Boyd to identify key goals and outcomes with him and outgoing deputy drug czar Tom McLellan.

As Addiction Today went to press, the US drug policy had not yet been released – but we give you a preview of its content. This is informed by insights from Tom McLellan and Keith Humphreys, who had a series of meetings with Addiction Recovery Foundation CEO Deirdre Boyd in London.

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Keith Humphreys PhD joined the White House Office of National Drug Control Policy as the senior policy adviser to the deputy director, working to integrate scientific information into policy. He was professor (research) of psychiatry and behavioural sciences at Stanford School of Medicine.

A Thomas McLellan PhD stands down in June as deputy director of ONDCP, after assisting  the formulation and implementation of the US National Drug Control Strategy. He has worked for over 35 years in addiction treatment research, most recently at the Treatment Research Institute, a non-profit organisation he cofounded in 1992. He has published over 400 articles on addiction research.

This month, the next UK government will start to draw up a national drug policy, drawing on proposals submitted to it by a range of think tanks and stakeholders. Across the Atlantic, the first US drug policy under president Barack Obama has been prepared – ready for publication, it was delayed by Obama’s release of controversial healthcare reforms. So is there anything new? And are there ideas worth adopting here?

“There are at least two significant changes from the Bush administration,” McLellan and Humphreys revealed.

“For the first time, the White House has an office for recovery [from substance abuse/dependency]. And this year’s drug policy will for the first time have a chapter on recovery.”

One indicator of changing priorities is that, when McLellan visited London this spring, he was on his way to Vienna to represent the US at the 53rd Commission on Narcotic Drugs – the first demand-reduction representative to do so. Usually, all the representatives are from law enforcement.

“Historically, 70% of funding has been for law enforcement and 30% for prevention and treatment. We hope to move demand-side budgets up to the level as supply-side,” he said.

“There is a pronounced change of policy,” Humphreys stressed. “The Bush administration policy was based solely on number of drug users – irrespective of severity of use or intensity of treatment. But chronic heavy users must have different treatment statistics.”

This is particularly relevant to the UK, where statistics do not differentiate between lighter users – who might need merely a brief intervention – and people who are chronically dependent. Rehabs and 12-step linked organisations have tended to treat the latter but this is not counted by government/NTA measurement tools.

“Aids was not included before,” Humphreys continued. “Drug driving and motor safety are also a new inclusion. And there is a chapter on data science.”

President Barack Obama had tasked the ONDCP to get out and meet agencies across the US before drawing up the drugs policy. Over 150 members of 34 federal departments and agencies participated in subcommittees to help formulate long-term policy goals for preventing and treating substance abuse, and input into budget guidance. They returned with the following priorities:

• create a national prevention system
• integrate prevention and care of substance use disorders into mainstream healthcare
• improve and expand evidence-based ‘specialty care’ for addiction
• create safe, coordinated managing/monitoring paradigms for drug-involved offenders, and
• a permanent performance monitoring system.

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US DEFINITION OF RECOVERY:

“A voluntarily maintained lifestyle characterised by sobriety, personal health and citizenship...
....with or without medications”

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"There will be a focus on prevention, early interventions, treatment and crime,” Humphreys and McLellan confirmed. “And we will use law enforcement differently... The three things science which has shown to work are prevention, treatment and enforcement.”

“For instance, research now shows us that addiction has an ‘at risk’ period. Prevention should be done throughout that period, not merely once or twice.

“Also, risks have common antecedents so single interventions can have multiple effects. We, and patients, do not need 164 different interventions – which is why we do not need 164 types of grants. We must simplify that. We need a few, as we also know that combined interventions give enhanced impact.”

Early screening goes hand in hand with cultivating “prevention prepared” communities, with particular focus on adolescence. “If people do not develop a disorder by the age of 21, they have a low chance of developing one,” McLellan explained. “If this risk period was identified for diabetes, they would address it; we must change the way we deliver addiction prevention services. And if we cannot prevent or intervene, let’s treat.

“The relapse rates for diabetes, hypertension and asthma are almost identical to the relapse rates for any addictive disorder – 50% per year. But when diabetics relapse, they are treated. Now it is time to close the gap between those who qualify for treatment and those who are not getting it.”

Mainstream primary healthcare should be at the centre of this, requiring culture change. “Most doctors are not trained in how to treat substance misuse – they do not see it as a disease/disorder.” Integrating addiction services into mainstream healthcare stretches from early screening through to an active role in their patients’ recovery.

_____________________________________________

"Methadone in the US and in the UK is like football in the US and UK: very different practices."

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“It is good business for addiction treatment programmes to cultivate medical referrals and work/support doctors as they begin a difficult job,” recommend McLellan and Humphreys. Both see the addiction treatment field as a business – with customers. “The most important is the patient. But there are others such as referrers. They want satisfactory products: outcomes.”

What do they see as official outcomes: “Reduction of use, definitely. Abstinence, ideally. Integration is key. Employment is another goal for outcomes. We want to reduce crime; there are many referrals from courts and the criminal justice system.  Families want an end to embarrassment and drunken violence.
“These are outcomes because, regardless of how they are attained, they are good things to achieve... During the course of treatment is a good time to mention outcomes. People can strive for them while in treatment. That is useful for patients, for therapists, coaches, AA sponsors.

“Not getting this right has resulted in the production and use of unnecessary resources as shown, for example, in getting referrals back from emergency room and trauma admissions.

To produce those outcomes, guidelines should be offered and applied from as soon as people are assisted. This could start with something as simple as early identification, screening before intervention. That will work for some people.

“For people with more severe problems, there are about 15 evidence-based therapies,” McLellan said. “Evidence-based means independent evidence in controlled trials. Some  medications appear to help. It is not about one method over another, but good versus bad practice."

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US PRIORITIES 2010

The first drug policy from President Barack Obama’s administration looks at five priorities:

• a national substance abuse prevention system – “the time is right,” explains McLellan, “as we now have a large evidence base to build on”
• engage primary care
• close the addiction-treatment gap
• special cases for offenders
• improve related data systems

_____________________________________________

“It is good to measure patients and outcomes monthly; it also proves demand from the start.

"The worst thing is to automatically give someone methadone without going through the screening, identification and brief interventions process. If people become stable, create healthy relationships, find employment, that would be fine – but that rarely happens. So we must review patients regularly – for example, a month later.

“Urine samples should be taken to confirm self reports. If they are positive, the professionals can follow through by saying something on the lines of: “You are drinking/using, your family is not happy, etc. So take counselling. Perhaps you need to be re-evaluated for other problems”.

The therapeutic goal is to move people towards those outcomes. Should we have different lists of outcomes for different people? “That is a conversation,” responded Humphreys and McLellan. “But certainly we should go for reduction with a goal of complete abstinence.

“Residential care is important and necessary, but follow-up and an aftercare plan are equally as necessary to sustain the work started in rehab. There is a long way to go to re-educate commissioners in this way of thinking.

“In the US, we were thinking about addiction as just a lot of drug use, so we have been purchasing stupidly. Commissioners claim to purchase a continuum of care: ‘we purchase detox from him, we purchase residential care from him, and we get outpatient care from him’. The problem is that there are no clear relationships here. I want to say ‘I won’t buy from anybody until you show me a package that’s going to meet their needs’.

“People receiving care in the public sector do not have much choice; it is the opposite to business. One way to give them choice is through vouchers for recovery which must be spent in the treatment centre or a support service. Clients become the purchasers. Trials show that those given vouchers are more likely to be clean and sober.  They give patients more control gives better outcomes. They vote with their feet.”

MANIFESTOS FOR THE FUTURE?

Below is everything we could find – unedited by Addiction Today – in the manifestos of the three main political parties about prevention & treatment of substance abuse and addiction*.

LABOUR PARTY MANIFESTO

“Alcohol treatment places will be trebled to cover all persistent criminals where alcohol is identified as a cause of their crimes...
On drugs, our message is clear: we will not tolerate illegal drug use. We have reclassified cannabis to Class B and banned ‘legal highs’. More addicts are being treated, with a higher proportion going on to drug-free lives.
We will switch investment towards those programmes that are shown to sustain drug-free lives and reduce crime.”

LIBERAL DEMOCRAT MANIFESTO

“Ensure that financial resources, and police and court time, are not wasted on the unnecessary prosecution and imprisonment of drug users and addicts; the focus instead should be on getting addicts the treatment they need. Police should concentrate their efforts on organised drug pushers and gangs.
Always base drugs policy on independent scientific advice, including making the Advisory Council on the Misuse of Drugs completely independent of government...
Move offenders who are drug addicts or mentally ill into more appropriate secure accommodation...
Clamp down on anyone who is aggressive or abusive to staff in accident and emergency departments. We would encourage better working relationships between hospitals and the local police to provide an increased police presence at times of high risk, and increase prosecutions. At the same time, we will ensure that problem drinkers or substance abusers are referred for appropriate treatment.”

CONSERVATIVE PARTY MANIFESTO

“At the moment, many prisoners leave jail and lapse back into a life of drink, drugs and re-offending. We will never bring our crime rate down or start to reduce the costs of crime until we properly rehabilitate ex-prisoners. So, with a Conservative government, when offenders leave prison, they will be trained and rehabilitated by private and voluntary sector providers, under supervision.
We will use the same approach that lies behind our welfare reform plans – payment by results – to cut re-offending, with organisations paid using savings made in the criminal justice system from the resulting lower levels of crime...
Drug and alcohol addiction are behind many of the crimes committed on our streets, but the treatment that too many addicts receive just maintains their habits.
We will give courts the power to use abstinence-based Drug Rehabilitation Orders to help offenders kick drugs once and for all. We will introduce a system of temporary bans on new ‘legal highs’ while health issues are considered by independent experts.
To reform our system of rehabilitation further, we will:
apply our payment by results reforms to the youth justice system;
engage with specialist organisations to provide education, mentoring and drug rehabilitation programmes to help young offenders go straight
pilot a scheme to create Prison and Rehabilitation Trusts so that just one organisation is responsible for helping to stop a criminal re-offending.”

* We  omitted general remarks re alcohol pricing. Also, there were general commitments to NHS  patients being diagnosed and treated on time; perhaps this could be applied to drugs/alcohol.

MEET THE POLICY SHAPERS!

Professor Keith Humphreys will speak at UKESAD. David Burrowes and James Brokenshire will also be offering insights into future policy affecting readers. 

WHO WILL TREAT THE YOUNG ADDICTS?

MEPHEDRONE TOLL  MOUNTS

In February, the UK’s only rehab for 11-18 year olds was finally forced to shut its doors. Within a month, mephedrone washed over these shores like a tsunami, producing a rising flood of addicted teens – with nowhere to go for safety. Sarah Graham reports on the wave of new drugs.

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One month after the closure of Middlegate Lodge, the UK’s only rehab for teenagers, the government’s Advisory Council on the Misuse of Drugs was hearing evidence on the drug mephedrone – meow meow, MCAT, bubble, sold as “plant food”, but in reality a powerful stimulant which originated in a chinese laboratory and which in less than 12 months produced a rising flood of addicted adolescents.

This cheap-thrill white powder is snorted like cocaine, taken in pills or injected and is being linked to at least 26 deaths.

As desperate parents catch up with what’s been happening under their kids’ noses, they are realising that there is no rehab to send these young people to: for detox, for treatment, and to get them out of harm’s way, apart from the influence of endemically drug-using peer groups. Behind all the media frenzy about the death toll is another story.

For those caught up in the long nights of mephedrone addiction, the future looks bleak. How has the UK got into this mess? And is there a way out of the “fiendish meph madness”?

Having set up a “Middlegate action team”, I am not giving up yet. We are on a mission – to build a bonfire of the vanities under the National Treatment Agency for Substance Misuse and the current government and hatch a new rehab, phoenix-like, from Middlegate’s ashes.

CREATING A CAMPAIGN FOR KIDS

Middlegate’s chairman, Chris Robertson, had called me at the end of January to ask for help raising media awareness of the precarious situation facing the five-bed rehab. I jumped on a train – along with a Free@Last TV crew – to Lincolnshire, on a fact-finding mission.

We began filming a documentary to try and understand why a rehab described by Ofsted as “outstanding” which has treated over 400 young people and has no competitors went from being full with a waiting list just a few years ago, to half the number of beds and half of those beds empty, with staff standing round twiddling their thumbs when there are clearly so many desperate young people in need of treatment.  
What we saw and heard shocked and sickened us.

The contrast between what Middlegate was offering – in its beautiful, safe, rural location and its impressive results: many drug-free, successful, happy lives for those lucky enough to go there – and the ugly politics, bureaucracy, waste of resources plus short-sighted stupidity and unfairness to other, less-lucky, young people who wanted help but who could not find a path through the complicated referral/funding maze.

Fuelled by a positive sense that Middlegate deserved helping and a fear of what would become of these most desperate and vulnerable teens without Middlegate, I traded a few nights’ sleep – my first missed in eight years of sobriety! – to launch the Save Middlegate campaign on Facebook and a No 10 online petition. We quickly gained momentum, collecting hundreds of signatures and started securing national media exposure, even getting a very sympathetic, double-page spread, in The Sun.

To assemble a committee and formulate a plan, we began holding meetings. We started with Addaction which, despite its Unfashionable Not Unimportant “£10million fundraising drive” around young people and addiction, sadly led to nought for us... except for seeing clearly how enmeshed and dependent on the NTA/government some of the big charities are.

We moved on to Kids Company, headed up by Camila Batmanghelidjh.  She  hosted us, then pulled out all the stops to help us, emailing all her supporters with a personal appeal. Buoyed by Batmanghelidjh’s endorsement and clever ideas – including cannabis camps – a quick succession of meetings (all filmed) pulled together an impressive, multitalented, Save Middlegate action team. This includes Middlegate’s loyal staff, Mark Johnson of User Voice,  Kathy Gyngell of the Centre for Policy Studies, Deirdre Boyd of the Addiction Recovery Foundation which publishes Addiction Today, Debra Bell of Talking About Cannabis, Clea Myers of Tweaking the Dream.

We began formulating a new business plan. Johnson and Gyngell brainstormed a pilot scheme to divert young people from the criminal justice system into rehab, to evidence that money spent on rehab is better invested than holding a young person in a more expensive, perhaps counterproductive detention centre.

THE MEDIA AS DRIVERS OF CHANGE

To get the media interested, we faced two challenges. The first was that Middlegate had been near closure the previous year, so this was déjà vu, not a new story. Second, the media like reporting bad news. So some people, such as Channel 4 News, were waiting for the “Middlegate is closed” press release.

One young journalist, Charlotte Ashton from BBC Switch*, stood head and shoulders above her older colleagues. She took on the NTA’s Rosanna O’Connor and exposed the flaws in its apparent obsession with “treatment in the community” and “secure units”, often based around methadone replacement therapy – how appropriate is this drug for young people in their developmental stages?

We concentrated on winning support for the big picture argument: that, as a rich country which can bail out its banks, we can easily afford one abstinence-based teen rehab in the UK, for the most desperate, vulnerable young addicts to be detoxed and treated alongside other young people. After all, South Africa can manage to fund rehabs and the US has dozens of teen rehabs for children from across the class spectrum, not solely for rich kids. Last summer, I visited five of Aspen Education’s teen rehabs in Utah; that’s five in one state alone.

There is ample good, solid, evidence from the US and from EU countries like Sweden that treating teens’ drug use and underlying issues a) works and b) is a very sensible, money-saving solution. If you bother to do the math on adding together all the different costs – health, policing, social services, housing, etc – which an adult addict can accumulate, we can be looking at saving hundreds of thousands of pounds.

Middlegate had many things going for it. Set in a beautiful, remote, environment far away from the abuser(s), dealers and pimps who act as the young persons “friends” back home, Robertson and his team had lovingly nurtured, a strong holistic, therapeutic, programme, delivered with a warm, family-like feel to it.
My communications brief involved telling people about Middlegate, as it had spent its money on treatment, not PR. I found myself alerting a very bemused British public – “Why only one rehab? Why is it closing?” – to the loaded-dice challenges facing residential rehab.

Explaining to journalists the ridiculously complicated multifunding stream system – at least three different funders for each young person – and why the National Treatment Agency is audited on numbers “in treatment” not drug-free successful outcomes, and why it will not refer outside a local area even where facilities do not exist there. And, yes, £3620 a week is a lot of money. But not when compared to a detention centre where these young people are often heading, or have been already.

HELPING HANDS FOR THE FUTURE

February was a roller-coaster of ups and downs. Some of the ups look really promising: Chris Difford from Squeeze (with me in photo on left) called to offer support, an acoustic fundraising set. DJ Fat Tony offered to host a club night. My friend Davina McCall regularly tweeted calls for support to her 250,000 “followers”.

They say miracles happen in recovery and later James Brokenshire, Conservative MP and shadow Minister for Crime Reduction, came to see me at my Harley Street clinic (see photo on right). We talked for two hours and agreed on almost every point (spooky). In fact, the Conservative Party is saying all the right things and promising to support our plans, if they gain power at the general election – results will be due in soon after the issue of Addiction Today with this article is published in May.

With daily-growing outrage from the public and a constant stream of journalists’ requests, media exposure generated three new funded referrals for children waiting to be admitted. But then disaster struck. HSBC bank would not extend the overdraft or wait even one more week. So, on 19 February, 25 staff were made redundant, when the liquidators were called in.

It was so frustrating to have Middlegate slip though our fingers just before the action committee’s new ideas for generating more income and moving away from relying on “the system” could take root.
After some tears, we have had to Let Go of the old Middlegate and all that it was. But we continue to work furiously to establish a new charity, to open a rehab in the spirit of what was.

THE MEPHEDRONE PHENOMENON

Fast forward to the end of March. Ironically, on the day the ACMD met to examine the case for classifying mephedrone, a five-minute film*² for Channel 4 News by reporter Keme Nzerem about the drug’s rapid emergence and endemic use by young people on the Isle of Wight highlighted the very young users and how the drug is seriously impacting on their mental and physical health.

Watching the mother of a 15-year old teenage girl talk about the hell that awaits her daughter when she finally runs out of the powerful stimulant ’drone and starts coming down after six days and nights of continuous use, she describes a now all-too-familiar pattern: the anguish of withdrawal, outbursts of anger and verbal abuse, leading on to the frightening violence she will face. The mother says she needs help. But who will help her and her child?

Desperate parents across the UK are experiencing this dangerous pattern of very heavy use of mephedrone followed by mood swings from elation to suicidal, and extreme behaviour change. Children become violent.

Stephen Welch, a father I spoke to at the ACMD open day, told me that, when he called his local drugs service – seriously worried that his son’s now daily dependent use is going to kill him – he was told to take the teenager to a hospital Accident & Emergency. He could not believe the lack of resources in the country and the apparent lack of knowledge that drugs workers were displaying about how to help a person stop using a stimulant drug.

According to Keme’s report, half of Year 10s (14-year old schoolchildren) have used or are using the drug.
My own client work in Surrey supports such a high statistic. One young man said to me that he cannot wait for mephedrone to be classified. It is being used by his whole group of friends and when he is on a comedown, he feels like he “doesn’t care if he lives or dies”.

So the race to shut the door on mephedrone is, sadly, after the horse has bolted and ran amok. Nobody knows how many of these young people are dependent users. But even conservative estimates suggest that 5-10% of regular users of such a more-ish, rapid tolerance building, psychologically addictive substance, will need professional help to come off it.

WE MUST BECOME LEADING-EDGE

The fraught debate around the lengthy process that led up to a Class B classification also led to more ACMD members resigning – although this could be seen as an opportunity to start afresh – and hammered more nails in the coffin of the ACMD/Home Office/government legislative process. The system is archaic in the face of the tsunami of new, inexpensive “legal” highs synthesized by chinese chemists, shipped to the UK by the 100kilo and consumed for as little as £10 a gram, by a virgin mass market of young people.

Teens have been lured into trying untested powerful drugs because they are seen as “legal”– so “must be safe”. These young people are not simply making bad life choices. They have been carefully groomed by sophisticated internet youth targeted branding: “meow meow” is genius.

Entrepreneurs are selling on the edge of legality: advising “not for human consumption” but without fear of infringing brand copyrights including Bart Simpson and other cartoons. Cutting-edge marketing and advertising strategies have been flooding the internet and even popped up on my MySpace and Facebook pages (yes, I was a little peeved). Purchasing 1gram to over 1000grams is enabled by oh-so-easy access through hundreds of websites using AlertPay and next-day delivery.

The move to classify mephedrone has already started to take effect. Some websites are closing down (hurray) and prices are going up, out of children’s price range. The next few months of stockpiling and selling will be interesting.

Yes, many of those addicted will turn to crime as the price climbs. They might also turn to other drugs. I have warned the ACPO Meth and Presursors Working Group (I sit on) that we might see a sudden spike in crystal meth* production and use. Meph is chemically very similar to meth and cocaine cannot come down in price much more. The quality is already so poor, in the UK, and this is part of why meow meow took off so much. It is a cheap buzz that delivers the bang for the buck.

With over 400 new chemicals in the wings, the game of classification cat and mouse is set to continue. I have been arguing for a new Q for Quarantined classification to take immediate effect when a new drug pops up on the radar. This would close down the window of opportunity for chemists to make their fortune while the state makes up its mind.

With each new drug comes its own problems. We are certainly winning the arguments about the need for teen residential rehab to provide a safety net for the young casualties who deserve the best treatment any civilized society can offer. But now we need action to follow through the arguments.

The campaign to open a new rehab is going well. We recently received a wonderfully generous gift of £40,000 from one donor, subject to our new business plan(s).

To everyone who has joined the Facebook Group and signed the petition, we thank you. To those who haven’t... do!
Your country’s young people need YOU!

*www.bbc.co.uk/switch/revealed/?story=drugrehab2010
*2 http://tinyurl.com/y8qqrwf

SARAH GRAHAM is director of Sarah Graham  Solutions (www.sarahgrahamsolutions.com) and a leading addiction and holistic health expert. Prior to coming into recovery in 2001, she worked as a creative in radio, TV and internet content production. 

UKESAD 2010: best-practice therapies

The 60 worldclass presenters for over 40 presentations at the 7th UK/European Symposium on Addictive Disorders will exchange international expertise to help your clients recover from addiction/dependency.

Topics include:

• Increase family access to treatment
• Working through the continuum of care
• Addressing the 'ism' - codependency
• Identify and treat grief, trauma, traumatic grief
• How to change someone you love
• Feelings beneath the rage: emotional competence
• What interventionists look for in a treatment centre
• Effective therapeutic treatments for offenders
• Avoid burnout: selfcare for professionals
• Creating resilience
• Effective group therapy, including gender issues
• Relapse prevention: relationships and dating anxiety
• Use neuroscientific discoveries in your daily practice
• The neurobiology of the recovering body
• Addiction alongside LGBTQii issues
• Intervening on sexually addicted clients
• Outside Edge Theatre Company: matinee play and debrief
• From offending to enriching communities
• Accreditation of staff
• Dual disorders
• Mindfulness medication & co-occurring disorders
• Mindfulness meditation - experiential sessions
• 12-step meetings (closed and open)
• Identify and tackle problems facing children and young people
• Treating the adolescent through to young adult... and more

PLUS... Policies from the next government, commissioning clinics, uniting doctors and addiction professionals, setting up abstinence service-user groups, book signings by Ukesad presenters who are also bestsellers, complimentary head/shoulder massages.

 

DON'T MISS OUT!

Get a full programme and registrations details here.

INCREASE YOUR REVENUE...

BUILD YOUR BUSINESS WHILE HELPING PEOPLE TO RECOVER

The elite interventionists participating  in the 7th UK/European Symposium on Addictive Disorders could fill all rehab places in the UK for a year.

They are reaching out to families across Europe, and seeking treatment organisations closer than the US to which they can also refer patients.

John Southworth and Ken Seeley of the Interventions TV series reveal what they look for when placing clients – incidentally, Southworth is also responsible for treatment outcomes for doctors, nurses, dentists and lawyers in Idaho.

Association of Intervention Specialists president Rebecca Flood explains how to set up your own intervention business.

Brad Lamm shares how to change someone you love by getting them into treatment.

Jane Mintz acts as a roving expert answering your queries.
You can also meet up with registered delegates who specialise in interventions.

All this is at...

BUILDING BRIDGES: HOW TO RECOVER FROM ADDICTION

13, 14, 15 May 2010
5* Grange City Hotel, by the Tower of London

Delegates: register here
Exhibitors: register here

Over 60 worldclass experts in how to recover from addiction/ dependence will share their knowledge and expertise with attendees at more than 40 presentations. UKESAD is the only event in the UK and Europe which has demonstrated how to achieve long-term, sustainable recovery.

THERAPEUTIC TECHNIQUES

Overviews and intensive therapeutic techniques at UKESAD to prevent relapse and sustain long-term recovery, especially where there are complex needs, include:

•identifying and treating grief and trauma
•treating adolescents through to young adults
•building resilience, to avoid emotional burnout
•effective group therapy, including gender issues
•how to build healthy relationships in recovery
•breaking free from codependency
•teaching clients emotional competence
•treating co-occurring mental-health disorders
•mindfulness techniques
•addiction complicated by gay, lesbian, bisexual, transexual, queer and intersex issues
•intervening on sexually addicted clients.

USE NEUROSCIENCE IN YOUR DAILY PRACTICE

Professor Carlton Erickson shares the latest research on how our brain chemistry determines addictive behaviours, and how talking therapies can, in turn, change brain chemistry. Dr Richard Seely explains how to optimise recovery through understanding its links with neurobiology. And Kevin McCauley reframes it all into social marketing techniques to get the message across.

SELFCARE FOR CARERS

The indomitable Max Cohen shares the lessons he gives his university students on avoiding burnout and compassion fatigue. Gillian Bridge teaches resilience. Delegates can also attend mindfulness sessions each morning, and gain support at daily open & closed 12-step meetings.

AMERICAN SOCIETY OF ADDICTION MEDICINE

We need doctors who see addicts as people not prescribing numbers, doctors who will work with therapists and counsellors for the benefit of clients/patients so that they can turn around their lives free of harmful substances. Reaching out to delegates are ASAM president Dr Louis Baxter, ASAM board member Dr Michael Miller and past president Dr Andrea Barthwell, who was also the White House deputy drug czar. They will be joined by Dr Oscar D’Agnone and others, to help establish best practice here.

TRAINING STANDARDS

A certificate of attendance will be provided for delegates wishing to apply for Continuing Education Credits. The symposium is accredited by UKPCBADC, the UK Professional Certification Board of Alcohol/Drug Counsellors, a member board of the ‘gold standard’ IC&RC International Certification & Reciprocity Consortiun of Alcohol & Drug Counsellors. IC&RC president Jeff Wilbee will again be at UKESAD for the third year running, copresenting with Strada’s Joy Barlow and others on the accreditation of staff.

THE NEXT GOVERNMENT: GUIDELINES FOR US ALL

Whichever party wins the general election in May, Conservative Minister for Justice David Burrowes and Minister for Home Affairs James Brokenshire have excellent histories of working for effective treatment and can steer delegates through future policy. White House drugs adviser Keith Humphreys joins the opening plenary to share joint thoughts.

WIN A WEEK IN ANTIGUA

Ending on a light note, one lucky delegate is guaranteed to win a Renewal Week, including all meals and accommodation, at Eric Clapton’s Crossroads Antigua, worth c£2,000.  All the winner need do is get there. Tickets £10 each or £20 for three, available only at UKESAD.

DON'T MISS OUT - REGISTER NOW!
Delegates: register here
Exhibitors: register here
You can also register by calling Suzanne Gooch or Melissa Gordon on 020-7233 5333.
More details at www.ukesad.org

WE ARE GRATEFUL TO OUR SPONSORS

They subsidise all delegate places, raising training and standards for the addiction-treatment field.
Click here and click on their logos in right-hand column to get more details.

FACE IT & FIX IT

Article by Ken Seely to follow by end-April.