Tackling heroin addiction – abstinence or management?

The rise in the number of heroin users has caused some experts to question the effectiveness of substitute treatments. Community Care asked two experts to give their views

Paul Hayes, chief executive, National Treatment Agency

When I first started working with drug users 30 years ago, abstinence was the only treatment in town. The only options were rehab or methadone (the standard treatment for opiate addiction) on a brief reducing scrip. Most of the users I knew quickly dropped out, or were kicked out, either for misbehaving in rehab or using in the clinic. In addition, levels of relapse after completion were high so many individuals chose not to enter the system.

After the advent of cheap heroin in the 1980s, drug misuse escalated, plunging the abstinence-based system into crisis. The Advisory Council on the Misuse of Drugs persuaded the Conservative government to focus on harm reduction in order to encourage treatment take-up and retention. This succeeded in holding down levels of HIV infection, and Labour has built on it through additional investment with the explicit aim of using the treatment system to reduce crime. This resulted in what we have today – more than 200,000 in treatment, low waiting times, high retention levels, increasing numbers completing, improvements in health and reductions in crime.

Compared with 1978 – or even 2001 – the modern treatment system is successful, and we should all be proud of it. However, it remains a job only half-done.

As critics of current policy point out, most drug users enter treatment wanting to leave as quickly as it is safe to do so. Too often the system is not ambitious enough on their behalf. The NTA is now addressing this under the new drug strategy.

As I see it, the problem with methadone is not that it doesn’t work, but that it works too well. Stability, improved health and reduced crime are necessary steps on the road to recovery and a drug-free life, but not the destination.

We need to balance the risk of relapse if people attempt abstinence, against the risk of inappropriately thwarting their ambition to become drug-free. The NTA believes in a balanced treatment system, in which a range of options is available from which users benefit at different points in their lives.

That means methadone is appropriate to start the process of getting heroin users off drugs. We make no apologies for that: the National Institute for Health and Clinical Excellence recommends it. It also means psychosocial interventions – so-called talking therapies – are on the menu, together with detoxification, offered in the community as much as in a residential setting. A variety of other non-medical help and support is offered too. And abstinence-focused treatment is suitable for some, when they are ready to take advantage of it and clinicians judge it will work.

Our aim is to get drug users into treatment so that they come off drugs. Some people are in treatment for a long time before they get to that point, but that must not make us complacent. To help users go beyond the stability that the scrip can establish and embark on meaningful change, is difficult, demanding, skilled work. Not all drug systems are commissioned to deliver it, and not all practitioners can. Nevertheless, our challenge is to address the ambitions of clients in the future.

Tim Leighton, director, Centre for Addiction Treatment Studies

It is difficult to know how many drug users there are in the UK, and how many have problems that need support and/or treatment. Recent National Treatment Agency figures show that 122,749 adult heroin users, 22,578 cocaine and crack users, and 13,422 cannabis users were engaged in treatment. The number of Britons who use illicit drugs at any level probably exceeds four million, most of those using only cannabis. Many are dependent and problematic users who want help.

In recent years more opiate users have been provided with better and faster access to methadone, and this has been seen as the most important treatment intervention. There is no doubt methadone is important, and plays a significant part in reducing crime, stabilising some users’ lives and reducing overdose deaths. However, many users and their families become dissatisfied with methadone, and find little help offered to come off this addictive and limiting drug.

In many quarters there is a feeling that our thinking about drug treatment must be revised. There is too wide a gap between receiving substitute prescribing (only really relevant to heroin users) with some supportive counselling (usually not much) and residential rehab, a drastic and intense ­experience for which a person has to be ready if it is to be successful. Proper pathways for users with serious drug-related problems, including severe dependence, need to be created to bridge this gap. Harm reduction and stabilisation should not be seen as opposed to abstinence. These should all be seen as parts of a process towards recovery which involves the reduction of drug-related harm and the development of personal and social benefits. A pendulum swing to an “abstinence-only, nothing else will do” philosophy will be as limiting as keeping things as they are.

Moreover, longer-term support, including self-help and community initiatives, needs to be provided after rehab. This does not have to be expensive but it may involve the development of roles new to the UK, such as the “recovery coach”.

Paul Hayes is right to defend the achievements of drug workers in the past 10 years, and there are examples of excellent practice in helping clients move into recovery. But many are stuck in “Methadonia” with no exit strategy. It is vital to move on with the serious support of recovery, reviewing the immense amount of research evidence, and creating pathways for people to follow. This does not mean coercion: some people may need to be on methadone long-term, a few may flourish on it. But we also need prescribing and harm reduction strategies to support those who relapse.

Route out of dependency: a case study

Addiction Dependency Solutions provides services in northern England to more than 17,500 individuals each year.

“ADS works with other services, such as housing, colleges and NHS treatment providers, to deliver a support package. As a modern treatment agency the aim is to ensure that every service user receives the right treatment package at the right time tailored to their individual needs and that of their families and friends,” says Tracey Hogan, director of operations at ADS.

“For some, this may be a tight series of targeted, focused individual sessions where needs are identified, concrete steps to change are agreed then acted upon and outcomes measured. For others, this may include a lengthier period of targeted treatment that includes psychosocial evidence-based interventions, cutting across areas that a client has identified as a problem, such as health, family, mental health, and employment.”

Clients are asked to rate how helpful every part of their treatment programme is and engagement and progress are measured at every opportunity in the treatment process.


 National Treatment Agency

 The Centre for Addiction Treatment Studies

 Addiction Dependency Solutions

 Essential information on substance misuse

This article published in the 6 November 2008 edition of Community Care magazine under the headline Methadone: is it time to kick the habit?

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