The latest Drink and Drug news contains more correspondence alleging that the NTA is pushing methadone and is not interested in people becoming drug-free, this week the allegation is the NTA does this to justify its own continued existence.

link is here to latest edition.
DDN'

Susi has written a riposte to Prof McKegany's previous letter, but seems a lonely voice.

Given that DDN is probably the most read journal in the field (on account of it being free, and there is a real possibilty that for some workers it is the ONLY journal they read), it seems that the role of evidence is not being given the importance it deserves.

Perhaps this is down to the voluntary sector, "do what we know is right" origins of so many providers. I am concerned that DDN appears not to be achieving proper balance in this regard, perhaps because those whose practice IS evidence based don't have time to write.

How does it seem to you?

This message has been edited. Last edited by: jimjones,

Hi Jim,

I think one of the problems with this debate generally is that its focused on organisations more than approaches. I know that Claire who is the editor of DDN welcomes and publishes all sensible correspondance.

I think the best place to keep the debate is focused on clinical and individuals decisions about what is best for them.

I'm not sure this is down to the the voluntary sector. To be honest one of the things that keeps coming up in sessions I'm running is that we have gone on and on about the evidence base as though it is an absolute objective truth for so long now we have forgotten that actually defining the evidence base is in many ways more of a political art than a science. Values based practice is the other equally important side of the coin.

Those who live by "the evidence base" can also die by it ....

Sara

http://www.independent.co.uk/life-style/health-and-well...lapsing-1522537.html

her is the last Inedpendent on sunday saying that "UK drug rehabilitation is collapsing" , seemingly because the government prefers to spoon out methadone.

"Because of changes in government health policy, private rehab centres are finding fewer and fewer health authorities are willing to foot the bill for addicts to have residential treatment, despite that fact that it is much more effective in getting them off drugs, according to the Addiction Recovery Foundation."


the article is full of odd sentances such as "
Up to now, rehab has been paid for by the drug abusers themselves or their local health service. But, increasingly, government policy supports putting as many addicts as possible into methadone-substitute programmes because they are cheaper.
"
It is of course supported by quotes from Prof McKeganey, but also worryingly for me, from Dr David Best, who i always think of as an evidence based guru, and is quoted as saying "the system has become saturated in methadone clinics, which are a much cheaper and easier way to 'treat' people."

Well i find all this a bit odd. My experience is that it is as easy or as hard now to get funding for rehab as it ever was. Locally people have to attend a social services organised assessment a few times, to listen to and think about discussion about the nature and risks/benefits of detox/rehab and be helped to work out if it is the right time for them to embark on this life change, and if it is, and they can turn up at the right time to explain this, then they funding is agreed and off they go, sometimes within a couple of weeks.

On any particular day, it seems to me that the majority of my patients do not want , (or could not cope for an enormous numbner of inidividual reasons,) to be uprooted from their home and shipped off to a rehab. I make it plain to them that if and when they would like to try that route, i'd be only too keen to support them and refer them, and indeed i am delighted when they go... even when the first attempt is sometimes a false start, and has to be repeated later. . I have not had the impression that the Governemnt or the NTA are trying to discourage this.

Does anyone good with figures (Susi maybe, or Hugo?)have the evidence base for the Independant article? I am a bit mystified (not an unusual state.. i was more at home building a rather handsome snow man this morning )

I know we were only approached for comment on Friday afternoon, so one could surmise that the article was pretty well finished by then. Most of it seems to quote annecdotal or individuals. I've just got into the office after a joyous four hour journey (cue mutterings derived from my time up north - "blimmin southerners, see a bit of white stuff from the sky and they faint") so will check with our comms as to whether we'll be doing a riposte.

One thing I did notice is that methadone does now seem to be bracketed in under the banner of harm reeduction services - I know it is on the continuum, as is abstinence, but is this a move to bracket everything together that is not overtly abstinence based?

quote:

"Because of changes in government health policy, private rehab centres are finding fewer and fewer health authorities are willing to foot the bill for addicts to have residential treatment,

(Independant on Sunday)

Do you know if the bit above is based on fact, Hugo? Have there been changes in government policy which might lead to less residential treatment? Have clinics closed, as the article suggests, and is there less residential dtox/rehab treatment gong on nationally? Or if some clinics have closed could it be because for whatever reason they haven't found their way into the market effectively? Or some other reason?

I certainly am aware of closures in this sector and other facilities tettering on the brink with insufficent referrals.
Running a rehab is not a get rich quick scheme?
Intersting to look at their unit costs,primarily salaries and those in other parts of the treatment industry.
The other important factor about rehab working is precisely because there is some judgement and criteria applied determining those likely to benefit from the rigours of this intervention.
These judgements are a mixture of science,instinct and determination in negoiating the hurdles prissing money from who ever holds the purse.

formal response should be available soon. In short Judith, I'm not aware of any changes in policy. Unless they are refrring to the NICE detox guidelines that say no to rapid detox?

Rereading the article it is (to me) a rehash of previous criticisms, which can be seen on the additction today website here. About half way down ont eh comments you can read my colleague Colin Bradbury's response to the allegations - yes, there are some that are strugling, but others reporting full occupancy.

One issue here which I think is worth exploring is whether presented with the option of good quality community treatment and support some people are choosing not to go away? I know for some people residential treatment is a good option, but many others I know prefer to stay at home - often having family commitments that make going away really stressful and difficult.

I also think some residential facilities are not very good and people - either service users or commissioners - are voting with their feet - or rather their community care budget. Regulation of the residential sector lags not just behind community treatment but also other residential services. There's a whole new group of places as well where they use housing benefit plus ptb or supporting people monies to make up a residential package and pretty much slip under the radar of everyones inspection.

If we think about other areas of healthcare, where equally positive outcomes can be achieved in the community we try to avoid hospital admissions. Why should drug use be different?

One final point, the Independent's reporting on drugs is always shit. I mean always shit. Its the worst of the "quality" papers and often gives the Daily Mail a run for its money in terms of misinformation and half truths - but all with the weary voice of liberal rectitude. I don't buy it anymore because of its drugs reporting. No that's not true. I actually don't buy it anymore because if I want to be told how to think and what to believe I'll get a copy of the Morning Star. At least their polemic has some humour to it ....and some balls. Oh and their sports coverage is good.

It is hardly surprising that some are reporting full occupancy when many others have closed. When 2 pubs locally closed before and just after Christmas I was left with little choice(bar drinikng at home,perish the thought) to frequent those still open and reporting full occupancy.

quote:

Originally posted by Sara McGrail:
<snip> one of the things that keeps coming up in sessions I'm running is that we have gone on and on about the evidence base as though it is an absolute objective truth for so long now we have forgotten that actually defining the evidence base is in many ways more of a political art than a science. Values based practice is the other equally important side of
Sara

This is the kind of thing that we have heard over the last few years as we have moved towards the "ROIS" model (Recovery Oriented Integrated Systems) in the North West.

second that. I remember being put ont eh spot a few years ago when, wet behind my newly appointed ears, I was banging on about the evidence. The question came "well whose evidence?". Though I welcome the rational influence of NICE, there is always the danger of an appraoch akin to the sensitive doorstaff the dodgy nightclubs I used to go to in Hull " If it ain;t RCT, you ain't coming in".

Anyway, Judith asked for it - the NTA line not necessarily on the IOS but in response to the recent 'debate' around res rehab. would be interested in any feedback

PEOPLE, NOT PROCESS

Drug treatment comes in a variety of forms. The most important thing is that the treatment any individual receives is clinically appropriate for their needs and circumstances.

The aim of all drug treatment services is to help addicts become drug-free. The focus of the NTA’s activities is to get drug users into treatment, and then ensure a positive outcome for those individuals.

The type of treatment and which organisation provides it are matters for the local partnerships that commission services on the ground in accordance with local needs.

The NTA’s concern is that the system works to give all drug-users the opportunity to become abstinent, and therefore successfully leave treatment. We are not in a position to prescribe what route is best for an individual.

Residential rehabilitation is one form of treatment. It is suitable for some people at certain times in their lives, but is not the automatic answer for every problem drug-user.

Advocates and interested parties may claim that residential rehabilitation is successful for heroin and crack addicts, and this view is supported by research, anecdotal evidence and common sense. However there is as yet no clinical evidence that would justify making it mandatory.

Last year the National Institute for Health and Clinical Excellence issued guidelines saying there was compelling evidence in support of two forms of drug treatment, maintenance prescribing and contingency management. It has not given specific advice on residential rehabilitation which would enable the NTA to instruct the field accordingly.

In the absence of specific NICE guidance, the NTA would expect commissioners to use residential rehabilitation as part of the broad mix of drug treatment services that are available in order to help individuals achieve abstinence.

This is in line with published research in the UK and USA that suggests inpatient-assisted withdrawal from drugs is more effective in a residential or specialist setting,

Nevertheless, an increasing number of partnerships are making legitimate commissioning decisions to invest in innovative service models, such as community detoxification or rehabilitation programmes instead of residential ones.


Residential rehabilitation is offered by more than 120 specialist voluntary sector or independent providers in England. However, it is only one element in a broad spectrum of treatment that is delivered in residential or in-patient settings, which includes NHS treatment. Together these are known in the trade as Tier 4 interventions.

Provisional figures from the National Drug Treatment Monitoring System show that in 2007/8 about 11,000 people used Tier 4 services; two-thirds (6,700) undergoing in-patient treatment in the NHS, and the rest (4,300) in residential rehabilitation.

This nominally represents just three per cent of all those in structured treatment - but the NTA believes it gravely under-estimates the true picture because not all providers of residential rehabilitation services supply figures to NDTMS. Residential rehabilitation is spot purchased by local commissioners according to local need, and the NTA has no power to compel independent providers to submit returns to NDTMS.

So what is the true picture? The NTA has undertaken an analysis using several different sources and calculated that in 2007/8 around 18,250 people accessed Tier 4 services – around nine per cent of the total treatment population (200,000).

This calculation was arrived at by looking at bed capacity and occupancy rates in the residential rehabilitation sector, plus access to other Tier 4 services.

• There are currently 2,182 beds listed on the Bedvacs database. The precise figure fluctuates according to market conditions. Since the average stay in rehab is three months, these beds could accommodate 8,728 individuals over a year.

• Some major providers (eg Turning Point) do not use Bedvacs. Information from the Healthcare Commission and the Commission for Social Care Inspection indicate there are another 980 beds not listed on Bedvacs, making about 3,000 in all. This equates to extra capacity for 3,920 individuals in a year, or 12,648 in total.

• However average bed occupancy in residential rehabs (in line with NHS custom and practice) is 85 per cent, so the total access figure should be revised downwards to10,750.

• In addition, NDTMS reports about 4,000 individuals accessed specialist in-patient detoxification services but did not go on to residential rehab, making 14,750 in total.

• A recent NTA survey further estimated that about 3,500 people every year go through detox in non-specialist hospital settings, eg general NHS wards, making 18.250 in total.

The NTA has no target for the proportion of the treatment population that should be in Tier 4 services. Internal information suggests that provision of Tier 4 varies widely across the country, and may be anywhere between one and 15 per cent of the local treatment population.

However (as above) the national average is nine per cent (or 11 per cent of the key audience of heroin and crack users in treatment). This is a useful benchmark for commissioners. Hence the NTA advised commissioners in 2006 that it would be reasonable to accommodate about ten per cent of their treatment population in Tier 4 services.

The Department of Health recently updated this advice by suggesting informally that the ten per cent benchmark should apply to residential rehabilitation or any other abstinence-focussed services, such as inpatient or community detoxification programmes.

Commissioning is a relatively new process, and there remains concern about the quality of commissioning services in the drug treatment field as well as the wider NHS. This was highlighted in the recent joint NTA/Healthcare Commission review of drug treatment services, and is being addressed in the NHS through the World-Class Commissioning initiative.

For example, the NTA/HCC review judged almost half of partnerships as “weak” when considering whether residential and inpatient services were commissioned in line with national guidance.

In particular, we know there is active antipathy among some commissioners towards residential rehabilitation, and passive resistance amongst some others who are not convinced of its potential benefits.

Accordingly, the NTA will shortly issue new guidance to all commissioners about improving the quality of Tier 4 provision through a best practice guide. This says:

• Tier 4 services have not uniformly benefited from the improvements in capacity and quality experienced by community-based treatments

• Tier 4 services can provide effective treatment for people with prolonged and heavy drug-use, and enable them to move towards abstinence

• Local partnerships should review their arrangements to ensure they are commissioning Tier 4 services in the most efficient way possible

Earlier this year, the Government announced an extra £54 million of capital investment to increase the availability of abstinence-based services by 2010.

The money is being allocated regionally, both to upgrade existing provision, and to provide more than 500 extra beds in residential rehabilitation, inpatient and other settings.

I think in this debate 2 seperate issues always get mixed-the abstinence/maintenance debate and the rehab/community treatment debate. When the debate is framed by rehab owners I do feel sometimes that they are hiding behind the abstinence/maintenance debate.
No one can disagree that becoming abstinent is what many service users want and we are much more focussed on that now than say 5 years ago. However, not everyone wants or needs to uproot and go to live in Western Super mare for 6 months. We developed an excellent community detox service in Wolverhampton and Birmingham's new tier 4 "Centre of Excellence" is due to open this year--this is a local facility which will provide detox, stabilisation and rehab services accross the residential/community continuum. Ten years ago when working in a commissioning dept. in Cardiff City Council I spent many long hours at the receiving end of the anger of residential home owners for older and disabled people not happy because they were going out of business as we developed domicilliary care services so that people could stay in their own homes. Its called "community care" or "care closer to home" depending on who you work for-some would call it progress! While some people will always need to "do a geographical" and move away to Western for a while-its also possible to destabilise addiction and begin long term recovery in the community-maybe with short flexible stays in residential setting--this is the model we are adopting in Birmingham (its a lot cheaper too-which means that more people can use the service for the same money). This will then be linked straight into supporting housing, peer support groups etc. Maybe the rehab industry needs to look at how it can become part of local/regional treatment systems providing a continuum of services across residential to community--and then it can "plug into" the natural supports people have in the areas in which they live.

quote:

Originally posted by Mercer, Tony:
<snip> its also possible to destabilise addiction and begin long term recovery in the community-maybe with short flexible stays in residential setting--this is the model we are adopting in Birmingham

This is also the model emerging in the North West.

quote:

Originally posted by Mercer, Tony:
However, not everyone wants or needs to uproot and go to live in Western Super mare for 6 months. We developed an excellent community detox service in Wolverhampton and Birmingham's new tier 4 "Centre of Excellence" is due to open this year--this is a local facility which will provide detox, stabilisation and rehab services accross the residential/community continuum. Ten years ago when working in a commissioning dept. in Cardiff City Council I spent many long hours at the receiving end of the anger of residential home owners for older and disabled people not happy because they were going out of business as we developed domicilliary care services so that people could stay in their own homes. Its called "community care" or "care closer to home" depending on who you work for-some would call it progress! While some people will always need to "do a geographical" and move away to Western for a while-its also possible to destabilise addiction and begin long term recovery in the community-maybe with short flexible stays in residential setting--this is the model we are adopting in Birmingham (its a lot cheaper too-which means that more people can use the service for the same money). This will then be linked straight into supporting housing, peer support groups etc. Maybe the rehab industry needs to look at how it can become part of local/regional treatment systems providing a continuum of services across residential to community--and then it can "plug into" the natural supports people have in the areas in which they live.

Great post - couldn't agree more

Sara

Coming rather late to this debate - most of the postings were at the beginning of the year, I would like to say that the anti-methadone thingy is alive and well and present in any pharmacy you care to name - it is present in the people that I meet, both professionally and socially, and if you don't believe me you pharmacists, next time you go to a different pharmacy, ask if they have any addicts, the response is amazing, mostly negative to what our goals are. Yes I know patients can be irritating in the extreme, but that is not to deny them a regime that works, the evidence is all there. No other field of medicine has such an evidence base.
If you want to read a real polemical account of how MMT does not work then read Theodore Dalrypmle, Romancing Opiates (I've probably told you all this before, but it bears repeating)
Regards
BobD

Theodore Dalrymple has a blog/website:

http://blog.skepticaldoctor.com/2009/09.aspx

Theodore Dalrymple has a blog/website:

http://blog.skepticaldoctor.com

Sorry for posting this link twice. I was trying to post a link to "he Ideas of Theodore Dalrymple"(.mp3 audio)an interview on the CBC Radio One show "Ideas" from September 2006.

http://www.skepticaldoctor.com...eches_and_Interviews

It's true that NICE hasn't appraised residential treatment, but that doesn't mean it wouldn't, if asked. Anyone can suggest a topic to NICE, and as a member of NICE's topic selection consideration panel for mental health, I can vouch for the fact that we see every single proposal that anyone sends in, even the rank barmy ones. If it is the general view of SMMGP that guidance on the place of residential care in this context would be useful, I'd be surprised if that did not carry some weight.

Workload means it wouldn't be done quickly. While RCTs are desirable, we're used to working with other forms of evidence.

While I am quick to say that you shouldn't suppose I have a local example in mind, I'm aware that the controlled drugs work my colleagues and I are doing arising out of the Shipman Inquiry has made commissioners aware in some areas that a number of private residential services are lacking in governance. I know of a couple of services that have not been recommissioned on grounds of poor clinical governance and while I have no reason to think that private providers are inherently any more likely to be deficient than anyone else, it may be that some have not been watching the changes over the last few years in the NHS managed sector and need some support from us to make commissioners feel more comfortable.