The end of addiction careers

1. The end of addiction careers DR DAVID BEST UNIVERSITY OF BIRMINGHAM BIRMINGHAM DAT / NTA

2. Treatment WORKS! • DARP • TOPS • DATOS • NTORS • DORIS • TREATMENT INTENSITY • ENHANCED SERVICES

3. 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

4. “A Chronic, Relapsing Condition” “As with treatments for these other chronic medical conditions [hypertension, diabetes, asthma], there is no cure for addiction” O’Brien and McLellan, The Lancet, 1996

5. People receive around 45 mins of contact time per fortnight or 18 hours per year … Best et al (submitted )

6. Numbers in treatment

7. Number of PDUs completing drug treatment as a proportion of discharges and completions

8. 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

9. 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

10. A clash of objectives Public health and safety OR Individual wellbeing The subtle incompatibility of goals across the addictions career

11. No Jail/Daily Drug Use (Male Opioid Addicts in DARP) 3 Years N=405; Simpson & Sells, 1990

12. Drug Use Outcomes: Community Treatment

13. Drug Use Outcomes: Residential

14. 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

15. Completed Heroin Careers

16. What finally enabled participants to give up?

17. What enabled people to maintain abstinence?

18. 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…

19. 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 (n=47) • Age of first AA meeting – 33.4 years (n=53) • Age of first treatment – 34.8 years (n=51) • Age of last drink – 36.5 years

20. Reasons for stopping

21. Reasons for staying abstinent

22. 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

23. 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 treatment’s ‘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

24. 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) PositiveNegative Higher motivation Burned bridges Tired of lifestyle multiple morbidity Amenable to change Few life opportunities PositiveNegative Still life options Low motivation Not imbedded in crime Still pleasurable drug use Non-dependent Substitution activities (CM?) Time

25. 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?

26. So why has treatment contributed so little to the process of recovery?

27. 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

28. 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

30. The Outcomes Star

31. 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