Drug Treatment

What Works?

Philip Bean, Teresa Nemitz, Philip Bean, Teresa Nemitz

• Publisher: Routledge
• Year: 2004
• ISBN:
  9781134496754
• Edition: 1
• Topic: Social Sciences
• Subtopic: Criminology
• Index: Social Sciences

Britain, like almost everywhere else, has a burgeoning drug problem. Finding ways of dealing with this problem is a major platform of government policy and a great deal has been made of the impact of treatment on drug users. Drug Treatment: What Works? is a cutting edge survey of the latest developments in these treatments, and it sets out to ask some of the crucial questions in the treatment of drug abusers; including: * Which treatments work with what sorts of abusers?
* What are the key indicators of likely success?
* Does coercion work or must treatment be freely entered into?
* Is drug testing an essential backup for successful treatment?Featuring contributions from some the leading figures in this field, Drug Treatment: What Works? will be essential reading for students, academics and professionals studying drug treatment in the areas criminology, social policy and medicine.

1 Introduction

Drug treatment; what works? An overview

Philip Bean and Teresa Nemitz

From the mid-1990s onwards British governments have increasingly allocated funds for the treatment of substance abusers – they recognise that treatment offers one of their few remaining options. Throughout this book we have wanted to look at the nature of treatment and consider why it should be given this priority. Treatment is defined widely; the definition given by the Royal College of Psychiatrists is used here; that is, as the prevention and reduction of harm resulting from the use of drugs (Royal College of Psychiatrists 2000: 155). Treatments taking place inside the criminal justice system are included, as well as the more traditional settings associated with and by reference to that provided by the National Health Service (NHS) or voluntary services. ‘Treatment’ is a ubiquitous term and we see no reason to restrict its use – at least until there is agreement generally about its nature and effects.

Treatment has been thrust into prominence for a number of reasons. One is the growing belief that treatment works, although as we say throughout this is more in the nature of a slogan than anything else; second, it is thought treatment helps reduce crime as there is a strong belief that drug taking causes crime. Overwhelmed by the increase in drug use and the apparent criminality it produced (‘apparent’ because the links with crime are more tenuous than they at first appear; see Bean 2001), the Government’s response has been to seek an ever-increasing number of treatment programmes. These, it is thought, provide relief from the revolving door whereby drug users move effortlessly in and out of the various systems, including the criminal justice system. A user whose addiction is out of control probably seeks treatment a number of times before treatment is successful (Gebelein 2000: 2).

This book deals with the nature of treatment, and some of the problems associated with providing treatment for substance misusers, as well as concentrating on criminal justice. Drug users are heavily concentrated in criminal justice populations. Studies in Britain also show that many arrested offenders tested positive for a range of drugs and were committing crime under the influence of numerous substances (Bennett 1998). A street heroin addict probably commits over 80 serious property crimes per year, alongside numerous other offences. High-frequency drug users tend to be high-rate offenders, yet periods in treatment produce dramatic reductions in criminality. The point is that drug use and criminality are inextricably bound together – and in saying this nothing is implied about whether one leads to the other. We believe that about 60 per cent of all referrals to treatment providers come from criminal justice, although no data are available, and we suspect that the figure could increase were more facilities available. These high-risk/high-need populations place considerable strain on existing services, as well as being excessively demanding in time and resources. They may not always be the most rewarding as patients – they are what has been described in another context as the unloved and unlovable – but they will continue to require treatment, and in ever-increasing numbers. Questions about the types of services provided and entry into those services require attention.

An overview and background to the belief that treatment works

In 1995 Tackling Drugs Together: A Strategy for England 1995–8 was produced for England; that for Wales and Scotland followed soon afterwards (HM Government 1995; Welsh Office 1998). Tackling Drugs Together committed the Government ‘to take effective action by vigorous law enforcement, accessible treatment and a new emphasis in education and prevention’ (HM Government 1995: 1). There were no details of the treatment programme in these Strategies, but promises were made that these would be provided in a later Task Force Report. The emphasis in Tackling Drugs Together was on reorganising local services, more often than not replacing them with Drug Action Teams (DATs).

In 1998 a second Drug Strategy was introduced by the newly appointed Anti-Drugs Co-ordinator, entitled Tackling Drugs to Build a Better Britain; The Government’s 10 Year Strategy for Tackling Drug Misuse (HM Government 1998). This largely reiterated the themes of the 1995 document, whilst adding performance targets for drug reduction for the next decade. Finally, in 1999 Guidelines on the clinical management of drug users (Department of Health 1999) gave advice to the medical profession about how best to implement the Drug Strategy (see Chapter 2 of this volume).

All these Government initiatives emphasised the need for treatment. It was to operate alongside law enforcement, prevention, and control – the latter mainly through the criminal justice system. Treatment was endorsed as a desirable platform in the Government’s strategy, which inevitably concentrated on Class A drugs controlled by the 1971 Prevention of Misuse Act, i.e. usually heroin and cocaine. In this, the Government called on the substantial evidence from America, but now transformed into British thinking, which shows that ‘Treatment Works’ – a slogan particularly favourable to Britain, which nationally has one of the most developed and widespread treatment services.

In April 2001 the National Treatment Agency (NTA), a Special Health Authority within the NHS was launched (see Chapter 7 of this volume). The NTA covers England; other arrangements are in place for Scotland, Wales and Northern Ireland. This statement of purpose is in line with the Government’s strategy ‘[t]o increase participation of problem drug misusers including prisoners in drug treatment programmes which have a positive impact on health and crime by 66% by 2005 and by 100% by 2008’ (ibid.) In February 2002 the NTA produced Models of Care for Substance Misuse Treatment, aimed at providing a framework ‘intended to achieve equity, parity and consistency in the commissioning and provision of substance misuse treatment and care in the UK’ (Department of Health 2002: 2).

The report sets out, or, rather, provides a consensus about the essential components of specialist substance misuse services and stresses the importance of links with other health, social care and criminal justice agencies (ibid.: 3). Its weakness is that there is little on criminal justice, where most of the problems lie and where a great deal of treatment should be directed. As a result the report places too much emphasis on medical matters such as blood-borne diseases, reflecting the strong medical membership of the project team responsible for the report.

Yet behind the slogan that ‘Treatment Works’ lie a range of difficult questions, many are rarely asked and most produce no easy answers. First, there is a group of empirical questions, such as: with whom does treatment work? Can successful treatments be given over a single period, or do they require subsequent treatments even if the first was successful? Is a single type of treatment appropriate to all patients? Then there are questions about the principles of treatment: what are the aims of treatment? What should be the remit, and to whom should it be given? Finally there are questions about outcomes: does treatment need to be voluntarily undertaken to be effective (see Chapters 9, 10 and 11 of this volume)? And what outcome measures should be used, abstinence or controlled use?

In Britain we rarely ask these questions, largely because we have not needed to, or, if we have, then we have preferred not to wait for the answers, for they bring to light matters we prefer to keep hidden. They demand evaluations about the way the treatment agencies operate. By implication they introduce pertinent questions about the distribution and location of services, and demand an examination of current practices. In short, they furnish a revolution, or if not quite that then something close to it. We hope that some of these questions will be asked throughout this book, and, if not, then hopefully later.

Looking through the British research cupboard we have to say it is fairly bare. One of the best and earliest pieces of research, by Hartnoll et al. (1980), involved a random allocation of patients to receive injectable heroin or oral methadone. The results showed that those who were given injectable heroin tended to remain in treatment, but, whilst fewer remained in treatment when on oral methadone, overall they had a better outcome. From this study in 1980 there was very little until the National Treatment Outcome Research Study (NTORS) in 1995 (see also Chapter 3 in this volume), prompted by the Department of Health Task Force Report (Department of Health 1996). The lack of research in Britain on drug treatment is little short of a disgrace and an indictment of the way research is viewed at Government level and beyond. The NTORS study provides the exception to an otherwise bleak picture. Local treatment centres have also been remiss, often failing to evaluate their programmes.

The nature of treatment

What do we know of treatment and how does it work? We have to say that little is written about it, but the literature, such as there is, suggests that the treatment of substance abuse involves a mixture of traditional medical interventions together with a range of therapies – the latter used more than the former. For a patient in the early stages of treatment the focus tends to be narrow, but broadens later to include different aspects of the drug takers’ lives (see Chapter 2 of this volume). The Royal College of Psychiatrists’ version of treatment, defined as being the prevention and reduction of harm resulting from the use of drugs, includes social, psychological or physical harm, and may involve medical, social or educational interventions, including prevention and harm reduction (Royal College of Psychiatrists 2000: 155).

This is an inclusive definition. It also sets out the treatment aims, which tend to be avoided in most definitions elsewhere. Textbooks on treatment usually begin with a description of the nature of drugs and addiction, then move to the process of treatment, i.e. to questions of assessment. Invariably this is followed by an examination of measures of intervention – usually including a discussion on the range of treatments provided and the special types of problems encountered – concluding with a section on follow-up and outcome. Central questions about aims and justification are neatly bypassed. In contrast, the Royal College has produced a more workable definition which provides a framework for treatment and defines the boundaries of the subject matter.

Treatment in whatever form, and for whatever group, deviant or otherwise, is derived from a theory of morals. It is aimed at producing an acceptable change in the patient’s behaviour – in this case reducing the use of drugs and preventing future use. Treatment is often presented as if it were solely a medical matter, whether conceptually or by the actions of the treatment personnel, but, as the Royal College definition suggests, this is not so. For whilst the language of medicine may dominate (as if treatment was aimed at curing an illness, the illness being addiction or substance misuse and being diagnosed after eliciting the signs and symptoms of the patient’s condition), in practice only a small part of the overall package may involve medicine, and then this is likely to be confined to the initial period of detoxification or withdrawal. The remainder is more about encouraging the patient to stay in the programme, resisting further temptation to take drugs, and leading a productive and useful life – as aptly described by the Royal College of Psychiatrists in their definition. Paradoxically a full-blown disease model is more likely to be found in Alcoholics Anonymous (AA) or Narcotics Anonymous (NA) in their ‘12-Step’ programmes – we say paradoxically, because the AA/NA model eschews the direct use of medicine in its treatment.

The stages of treatment invariably follow a set pattern, although an ever-widening range of treatments is available. Basically there are four, possibly five major treatment modalities: detoxification, outpatient drug-free programmes, methadone maintenance (or other maintenance programmes which might involve heroin prescribing) and therapeutic communities, the latter coming in various forms, whether religious or secular.

Anglin and Hser say these four types accounted for over 90 per cent of all patients in treatment in the USA in 1987 (Anglin and Hser 1990: 397). In Britain some patients are also treated by their general practitioner (GP), so that might perhaps reduce the American figure to about 80 per cent. Medical detoxification is usually the first stage. This itself does little to change long-term drug use but it safely manages the acute physical symptoms of withdrawal. Of the four modalities, detoxification is less concerned with producing therapeutic endeavours, and is more to provide symptomatic relief from the opioid abstinence syndrome while physical dependence on the drugs is being eliminated (ibid.: 423). Detoxification provides a gateway to treatment, encouraging users to avoid what they often fear most, the withdrawal symptoms of opioid use. For those unable or unwilling to withdraw maintenance medications are available, of which the most widely used is methadone – in Britain heroin/morphine is still prescribed by some licensed physicians; the number of patients receiving maintenance heroin is not known but is thought to be about 500 (Home Office, personal communication with the authors).

Once off drugs, i.e. once through the detoxification programme, other treatments are available, whether as an inpatient or outpatient, usually given as therapies such as Motivational Enhancement Therapy, Behavioural Therapy and Relapse Prevention Therapy, etc. The aims, however, are the same: to return the drug user to productive functioning in the family, workplace and community (see Chapter 4 of this volume). The best, or rather the most comprehensive programmes provide a combination of these therapies.

Nowadays treatment providers increasingly have patients with two or more comorbidities – i.e. suffering from the so-called dual diagnosis condition, which often means substance abuse and mental disorder, but could equally involve HIV/AIDS. These patients place additional burdens on the treatment services. Diagnosis is difficult as the conditions mimic and mask each other. For example, the hallucinations produced by some of the drugs (e.g. LSD) are the same in form and content as those in schizophrenia. The presence of one condition may mask the other – as where cocaine use covers up an endogenous depression or heroin use covers up phobic anxieties. Then there are questions about treatment: which condition to treat first? That which occurred first or that which is the most severe? And is treatment to be the same for both conditions? Many psychiatrists are uncomfortable treating substance misusers, who are invariably disruptive and take up a disproportionate amount of time and effort. Similarly, many treatment providers are ill equipped to treat mental disorders. Dual diagnosis patients simply add to existing difficulties for patients and staff (see Chapter 5 of this volume).

We have little data on the treatment personnel. Anglin and Hser say that the philosophies and policies of providers of treatment services are more diverse than the programme modalities, components and approaches, but even in the USA these are the least quantifiable and least studied features of treatment programmes (ibid.: 441). However, some programme staff provide individual and unique interpretations of the programme, often with considerable success. Anglin and Hser cite American research evidence which shows that some programmes are more successful than others even though the philosophy and patient group are similar. Differences in outcomes are related to the quality of staff as much as the quality of the programme, although the more flexible the programme the better the success rate (ibid.: 441).

Little is known about the cost-effectiveness of individual treatments – few long-term studies are available. The American National Institute on Drug Abuse (NIDA) reports that treatment is less expensive than non-treatment, as the latter often involves incarcerating the drug users in prison. According to other estimates, in drug court, for example, for every $1 spent on treatment $7 is saved – the costings are complicated and include savings on health care, as well as from policing, etc. (NIDA, quoted in Bean 2003). NIDA adds that ‘major savings to the individual and society also come from significant drops in interpersonal conflicts, improvements in workplace productivity, and reductions in drug related accidents’ (ibid.; see also Chapter 11 of this volume). In Britain NTORS, which followed the progress of 1,075 clients in treatment, the majority of whom have been opiate dependent for many years, calculated a return of more than £3 for every £1 spent on treatment, this saving coming mainly from the criminal justice system (see Chapter 3 of this volume).

Governments wanting further justification for expanding treatment services have seized upon this data, especially when backed by statements such as the following: ‘It is an inescapable conclusion that treatment lowers crime and health costs as well as associated social and criminal justice costs’ (Lipton 1995: 520). However, some critics dispute these figures, arguing that the criminal justice system benefits little from treatment programmes, for the amount saved by a small reduction in the prison population is negligible, and immediately offset by an enormous cost involved in expanding existing treatment services. To offset these there may be savings in other parts of the health system, and in social terms treatment may produce a reduction in criminality. Even so, savings are difficult to calculate; for example, how to measure the cost of a reduction in the fear of crime? The ease with which these figures have been accepted suggests they provide information that is welcomed.

Until recently the data, such as there was, came from the Regional Drugs Misuse Databases (RDMD). In 2001 a census was carried out of all drug misusers in treatment during April to September 2000, taken with routine RDMD data. These databases routinely collected data on users presenting for treatment for the first time, or for the first time in six months. These databases were later replaced by the National Drugs Treatment Monitoring System (NDTMS), introduced on 1 April 2001, which improves the quality of data by including more information on those in treatment. Results show that in England during the year 2001:

• The number of users reported as being in treatment with drug misuse agencies and GPs was around 118,500.
• This compares with around 33,100 who presented for treatment for the first time, or for the first time in six months or more, during the six-month period ending 30 September 2000.
• About one-third (32 per cent) of users in treatment were under the age of 25 years.
• The great majority of users reported as being in treatment (87 per cent) were attending community specialist services – these were thought to include community-based drugs services, hospital outpatient and drug dependency unit outpatient services.

(Department of Health 2001)

These results are not surprising, especially those that show only 32 per cent in treatment under the age of 25 years, even though most drug users are under 25 years. There is an enormous gap between those receiving treatment and those needing it or who would benefit from treatment were it available. The size of that gap is difficult to determine but it probably understates demand by a factor of 10. Add to this another group called therapeutic addicts, whose addiction comes from medical over-prescribing. These people are almost always disregarded when we talk of substance misuse yet they take huge quantities of prescribed drugs (see Chapter 6 in this volume). They are often over the age of 45, antecedently non-delinquent, and rarely see themselves as addicts yet might freely admit they have a drug problem. They eschew notions of addiction yet exhibit all the features of the street junkie when they seek the drug of their choice on demand. Assuming that every GP in the country has between eight and 10 of these patients, the numbers nationally must be huge. Bringing this group into treatment is another mammoth task.

The data in Britain is simply not available to determine with any degree of certainty that treatment works. Long-term studies are nonexistent; nor are there many which have evaluated the programmes. Looking back over the last decade or so we need to ask why so little research was undertaken. The opportunities were there but were missed and chances ove...