Friday, 2 May 2008

Providing opportunity, choice and hope

In November last year, I spoke at the Annual Conference of the Federation of Drug and Alcohol Professionals (FDAP). I was one of five speakers asked to participate in a symposium on the first 10-year UK drugs strategy and the future of treatment. My remit was to talk about the importance of empowerment and self-help.

I took this opportunity to put over the Wired In vision of what treatment and recovery support services should look like in the future. Please take a look at my presentation and let me know what you think.
At the start of the talk, I emphasised that whilst the system has made some significant achievements over the past 10 years, this was not surprising as a lot of money had been invested. I pointed out that if we were not careful, we faced the possibility of an American-like situation, where there was a massive disinvestment in treatment in the late 1980s-early 1990s after years of over-promising and under-delivering.  
I outlined a number of problems in the current treatment system and emphasised that we needed to change focus towards the person and towards recovery.  
I talked about recovery, recovery communities, behavioural change, principles that underlie successful therapeutic interventions, and treatment. I also emphasised how important it is to focus on 'the drug, person and social context' (drug, set and setting), rather than just 'the drug'.
A number of different key concepts were brought together into a model of how we should be viewing the process of helping people overcome substance use problems. In the time available, I could only discuss a limited amount.
Here, I give you the opportunity to read and think about what I had to say. Over the coming few weeks, I will blog on a variety of the topics and issues contained in and around this talk.
I believe strongly that we need to make significant changes in the current treatment system. I also believe that there needs to be a significant enhancement in understanding amongst the treatment workforce of what it takes to help people overcome serious substance use problems (i.e. recover from addiction). 


Dr Dave said...

I think your presentation is spot on. We currently have a treatment system which has low aspirations for clients. Because of the focus on opiates and the set up of methadone filling stations, we have most of our eggs in a basked with 'don't even think about recovery' attached as a label on the side. I agree that there is lack of understanding of addiction as being the problem.
Plugging people into recovery communities and ensuring robust aftercare following treatment are essential, as treatment is a way station only on the recovery road. A lifelong care plan will be needed.

There is another issue with methadone. We know that heroin, stimulants and alcohol reduce the number of dopamine receptors available in the brains of addicts/alcoholics. These are the 'feelgood' receptors in the brain. In effect it gets harder and harder to feel normal pleasure, the only blip on the pleasure radar coming from using drugs which release huge amounts of dopamine. It seems likely that methadone does the same. If you are flat, pleasureless and demotivated as a result of depleted dopamine receptors it is harder to find the internal resources to move on. Abstinence is often the platform to start from. We know the receptor status is creeping back towards normal over that first year or two of being substance free. The pleasure desert gets some rainfall and begins to bloom. I see it like this. Methadone is a sticky drug. If you spill it, it makes a sticky mess. It is sticky metaphorically too. People find it difficult to move on from. What if our methadone programmes were making it harder for people to recover rather than assisting the process?

Dr Dave said...

I agree, I agree, I agree!

Peter O'Loughlin said...

David ,

first thank you for the link to your presentation at the FDAP conference, I recall the coverage given to it in DDN, and the stark contrast in your focus on recovery as compared with other speakers.

There is so much I could comment on in your presentation, on this occassion, I'm going to confine my comments to the items on page 6 since they're so close to my heart and experience, and I have to say that there have been times when having commented on such issues myself, i have felt like a 'lone voice in the wilderness', with the only feedback being mainly negative.

Numbers in 'treatment', and the period they are there for, rather than the outcome of the treatment, is such a simplistic concept, I'm astonished as to why it has ever been accepted as a measure of success. It is almost impossible to find any factual information about the numbers who are discharged drug free,and subsequently remain so, which in itself exposes the weaknesses in the current strategies.

That leads to the next point of what the 'treatment' consists of, which as you so succintly point out is the trading of one addiction for another. I call it 'feeding the addiction', not treatment, since the concept the latter treatment should intially be the alleviating of symptoms, followed by recovery.

That leads to your next bullet point, using methadone as 'substitute', in more ways than one, in my opinion, it delays and all too often prevents entry into recovery. A concept that as you then point out is alien to to both commissioners and practitioners. Rather than treating the addict, we are feeding the addiction, thus keeping people locked into that state. Is it any wonder that peole are not getting well? What hope is there for reintegration, if all we can be bothered to do is to keep people locked into a semi comatose state? that is not in any way meant to be disrespectful to those who are on MMT, but as an observation of what I see week in week out, and where any will, or resolve on the part of the addicted to enter into recovery is gradually being eroded; its almost as if there is a malignant force at work denying the right of those addicted to become drug free. A possibility that gained credibility, given the response by highly influential organisations and individuals,to the the comments about methadone in 'Break Through Britain'.

Yes MMT does have a role to play, but not as a 'substitute' for recovery, it is far too limiting in its present administration.

david said...

Excellent presentation. Will be referring to it as it put together very well a lot of the key issues being faced in the field and issues I have struggled with in relation to our treatment systems, attitudes and strategic approach. Just to note that the opiate focused, current and historical, is even more unhelpful when working with young people i.e. the negative effect is exaggerated. It also demands expensive treatment systems (drugs and medics) that are largely unproductive and certainly in many cases counter productive (whilst accepting there is a role for MMT).

Once again thanks,


Prof David Clark said...

Dr Dave,
Yes, what if our methadone programmes (MPs) are making it more difficult for people to recover rather than assisting the process? Yes, could well be. But I wouldn't say MTs per se, rather poorly run MPs where they are not part of a menu of options in an overall programme directed towards helping the person find recovery. I wonder how many bad MTs there are nationally.
Have to be careful here though because some people do find their personal recovery on a MP - although they may want more later, or may not.

Prof David Clark said...

Thanks for thoughts. We're close to finishing an overall Wired In statement on these issues. Need to make sure it attracts attention and try and get some discussion.