For many years, drug addiction treatment in the UK has been marred by dispute and confusion. All too often, the debate around how best to treat those with a drug addiction has seen people divided into two camps: those who promote abstinence and those recommending substitute prescribing. This lack of nuance has seen too many people ‘parked on methadone’ indefinitely, based on a system that focuses solely on harm reduction; while the alternative, abstinence, has problems just as significant, and can result in dangerous relapses.
Against this backdrop, the National Treatment Agency’s recent report on prescribing substitute medication is a breath of fresh air, finally formalising the ideas that have been developing in the sector over the last decade.
The reality, as is expressed so clearly in the recent report, is that the abstinence versus prescribing debate is a false dichotomy: we don’t have to choose one or the other.
I have specialised in addiction treatment for more than five years. Through my work with the national health and social care charity, CRI, I have come into contact with thousands of individuals, and one thing I have learnt for sure is that every situation is different. Addiction is a very personal matter – it’s tied to medical and social factors that go far beyond the basic question of how much of what drug they are taking.
What doctors and treatment organisations in this field must do is develop a holistic approach that uses whatever approach is best for the individual.
For this reason, every treatment programme must be considered individually. For some patients, abstinence-only approaches might be effective, but for others they could turn out to have disastrous consequences. For many, prescribing a substitute drug gives them the opportunity to quit street drugs, stop committing crime, preventing viruses like Hepatitis C or AIDS from spreading, and enter a structured recovery programme, but the ultimate aim must be becoming free of dependence on drugs wherever possible. We all know that for many this option will be very difficult to achieve and could take many years; even if they never manage to get off drugs or substitute medications, we should work in partnership to help them to recover other aspects of their life that could have been neglected when all the treatment they have received over the last ten years is just a methadone prescription.
There must also be more of an emphasis on personal responsibility: treatment must be a partnership between the doctor and the individual. GPs have a responsibility to consider the individual’s circumstances, to make sure they understand all of the options available to them. Likewise, the individual must, based on informed consent, take charge of their treatment programme.
So how should doctors start putting this into practice?
On the clinical side, this may include optimised doses of appropriate medications, and the reintroduction, reduction or dropping of supervised consumption as appropriate so the patient can improve self esteem, confidence and freedom. Patients should be offered the opportunity to come off medication at a rate that works for them. If agonist or antagonist medications are being prescribed then the GP should work jointly with each patient to assess the benefit still being obtained.
What’s vital is that prescribing is part of a holistic approach. It must sit alongside case management and psychosocial interventions. Exits from treatment must be visible to individuals from the minute they walk through the door of your service: offer links to a recovery community or employ ex-service users as recovery mentors and coaches.
Efforts should be made to strengthen or develop patients’ social networks, involving families where appropriate. Ensure they are able to access support around employment and housing; essentially, services need to help them plan and build a new life. Measurement of progress must take into account quality of life factors as well as simple clinical data.
Taking these steps at services across the country will lead to better outcomes for individuals, as well as for society. It is time to end the division within the sector around recovery methods and pathways, and put the needs of drug users first by recognising that there are numerous pathways to recovery.
Dr Giani Barone is a GP in Greenwich, and the Crime Reduction Initiative’s clinical lead for drug and alcohol services in the area.