The end of addiction careers

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The end of addiction careers

• DR DAVID BEST
• UNIVERSITY OF BIRMINGHAM
• BIRMINGHAM DAT / NTA

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Treatment WORKS!

• DARP
• TOPS
• DATOS
• NTORS
• DORIS
• TREATMENT INTENSITY
• ENHANCED SERVICES

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What Do Eminent International Experts Tell Us?

• Addiction is not self-curing. Left alone,
  addiction only gets worse, leading to total
  degradation, to prison, and ultimately to death
• Robert Dupont
• Director of NIDA
• 1993

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A Chronic, Relapsing Condition

• As with treatments for these other chronic
  medical conditions hypertension, diabetes,
  asthma, there is no cure for addiction
• OBrien and McLellan, The Lancet, 1996

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People receive around 45 mins of contact time per
fortnight or 18 hours per year
Best et al (submitted )
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Numbers in treatment
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Number of PDUs completing drug treatment as a
proportion of discharges and completions
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Cultural effects of this model

• Disillusioned and instrumental staff
• Low expectations of clients
• Low expectations by clients
• Stigmatisation of treatment
• Methadone, wine and welfare
• Net widening without commensurate changes in
  modelling of treatment

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What has gone wrong with structured day treatment
TARGETS
Quantity Over Quality
Morale collapse contagion
Methadone, wine welfare
Working in a tap factory
Methadone based treatment
Instrumental working
Models of chronic, relapsing condition
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A clash of objectives

• Public health and safety
• OR
• Individual wellbeing
• The subtle incompatibility of goals across the
  addictions career

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No Jail/Daily Drug Use (Male Opioid Addicts in
DARP)
3 Years
N405 Simpson Sells, 1990
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Drug Use Outcomes Community Treatment
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Drug Use Outcomes Residential
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End Of Careers Study

• Sample of 187 former addicts (alcohol, cocaine
  and heroin) currently working in the addictions
  field, from total group of 228 former users
• 70 male
• Mean age 45 years
• 92 white
• Worked in the field for an average of 7 years

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Completed Heroin Careers
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What finally enabled participants to give up?
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What enabled people to maintain abstinence?
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Qualitative data

• 12-step played a prominent role in achieving
  abstinence and particularly in maintaining it
• However, it appears to have coincided with
  psychological and environmental changes
• Readiness, awareness and insight are the main
  features that differentiated final success from
  previous attempts
• Formal treatment appears to have played a
  relatively minor role, and can act as a barrier

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Follow-up work

• Sub-sample of 63 dependent drinkers
• Started drinking daily at 21.3 years
• Age of self-reported dependence 25.6 years
• Age of first quit attempt without treatment
  31.7 years (n47)
• Age of first AA meeting 33.4 years (n53)
• Age of first treatment 34.8 years (n51)
• Age of last drink 36.5 years

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Reasons for stopping
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Reasons for staying abstinent
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So where is this work going?

• Third wave of survey data to be collected
• Focus on outcomes and aftercare for day
  programmes and community groups
• Development of a recovery network for policy and
  research purposes
• Develop new techniques for sampling

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Why is this research important?

• Because no other researchers seem interested in
  asking these questions
• Because we base our evidence on in treatment
  populations and those who experience treatments
  revolving door
• Because of an increasing commitment to treatment
  careers and completions
• Because of the salience of ISG clients in
  treatment services, failure is over-stated and
  the biological model dominates

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Are there windows with increased opportunity for
recovery?
Intensity/Severity
Prolonged dependence/ learned helplessness
Harm min (MMT/BMT)
Pre-dependence (Escalation)
Maturing out (De-escalation)
Positive Negative Higher motivation Burned
bridges Tired of lifestyle multiple
morbidity Amenable to change Few life
opportunities
Time
Positive Negative Still life options Low
motivation Not imbedded in crime Still
pleasurable drug use Non-dependent Substitution
activities (CM?)
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Is there a window for recovery?

• . And does it fit with a back door to the
  treatment services?
• Evidence biased in favour of maintenance but
  little done on routes out of addiction and on
  supporting long-term recovery
• Aftercare?
• Housing?
• Employment?
• Can treatment and mutual aid be reconciled
  effectively?

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So why has treatment contributed so little to the
process of recovery?
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Failures of evidence

• Tier 4
• Aftercare
• Community detoxification
• Complexity of treatment journeys
• Failures of joint working
• Leaving us with an evidence base predicated on
  the medical / biological with little knowledge of
  social factors that predict success

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Conclusion

• Drug treatment has become a population management
  strategy
• Failure is salient and success is hidden
• Only recently is abstinence becoming an
  acceptable aim to clinicians
• Irrespective of intensity and severity, addiction
  is a career, not a chronic, relapsing condition
• The key is recovery journeys that emphasise
  routes to abstinence and mechanisms for
  maintaining it

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The Outcomes Star
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And finally

• Addiction careers are not predictable but this
  study suggests that we do not have to commit to
  the chronic relapsing condition mantra
• It is crucial that this message is disseminated
  to users and to workers alike
• Treatment purgatory cannot be perceived as a
  desirable state of affairs
• We need the evidence to promote this through
  policy mechanisms