Promoting abstinence for drug users is about saving money not scienceBMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f1481 (Published 22 March 2013) Cite this as: BMJ 2013;346:f1481
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The title of Jason Luty’s Personal View, Promoting Abstinence for Drug Users is Bad Science (BMJ 2013;346:f1481), is misleading and erroneous.
His early premise is that this policy is recent and based on an economic platform. The Labour Government introduced Tackling Drugs Together in 1998 and the face of political opposition. They funded the programme from Health and Criminal Justice monies through Local Authority Crime & Disorder Reduction Partnerships. Their centralist controlling approach insisted upon a strong monitoring force and the National Treatment Agency was formed. Since then the local commissioners, Drug & Alcohol Action Teams, have been straight jacketed by their monitoring systems and demands, at least until the 2012 Health & Social Care Act.
Ten years after introducing the programme the Labour Government was hearing increasing voices of discontent from users, organisations supporting the psycho-social care of users and families, and even some clinicians, especially GPSIs. They reviewed the prevailing system and produced a new policy in 2009 which refocused the system on to a Recovery model. They lost power shortly after this and the Coalition Government affirmed this approach in the 2010 National Drugs Strategy. The Strang report, Medications in Recovery, was part of the National Treatment Agency’s attempt to retrace its steps.
The policy was not a response to the economic climate but increasing disquiet amongst users and support organisations. It also reflects the fact that the cohort of opiate users is getting smaller and older. Younger people are using a myriad of recreational drugs, none of which have a substitute the pharmaceutical and medical professions can offer as the magic bullet. We still need to attend to the needs of these people even if crime does not feature so strongly in their addictive behaviours.
Policy is never based solely on the evidence of science, there are other influences to consider. The programmes of interventions which spring from that policy however must have some serious evidence of benefit and effect. Policy on the other hand will always have sociological, ideological, cultural, ethical, and financial influences.
The evidence referred to by Luty concerning the ineffectiveness of abstinence is biased by the fact that there is usually little care taken about the psycho-social interventions or changes used in these settings. If the medical model is dominant, the users are often left to their own devices to cope as abstinent. The need to assist or identify the personal drivers and triggers of their addiction, steps to take to achieve stability in relationships, especially family and parenting, work, and housing are very well documented in the addiction literature. The dose and frequency of these is less well described in these researches than would be the case if it was a drug trial.
Luty is, however, probably very right when he argues that rather than monitoring the recovery programme so closely, and unprofitably, steps to ensure true partnership working between clinical and psycho-social arms of this approach must be achieved. Luty refers to this as streamlining the system. There is evidence in many parts of the country where this has developed over the past two years and thankfully the National Treatment Agency’s absorption into Public Health England may assist this.
If Public Health England make the same mistake in believing that measurement of ‘hard data’ and setting targets with perverse incentives, as is currently the case, is the right way to continue to go then the Recovery Programme will not serve users well. Target driven enforced abstinence certainly will not work.
Competing interests: No competing interests
It cannot be denied that alcohol and tobacco are as dangerous as heroin and cocaine. On the basis of harm it is no more or no less wicked to use alcohol and tobacco as to use heroin and cocaine. It is an acceptable therapeutic outcome for a very heavy drinker even if dependent to control their alcohol intake at a harm free level. Even if a heroin user is doing very well over a long time on a stable prescribed dose of methadone he will be considered a therapeutic failure to be ushered towards abstinence. The drive to abstinence is unethical practice driven by an immoral agenda based on prejudice and not by clinical need. It is Laws that make crimes not immoral an indeed moral acts. We must have profund concern if we criminalise acts such as taking heroin and cociane when morally equivalent acts such as taking alcohol and tobacco go unpunished. I am horrifed by the hideous sentences passed by Parliament and imposed by our Courts on drug suppliers and users. We refuse to see that suppliers and users of currently illcit drugs are no less a persecuted minority and suffer greater sanctions than even those that the male gay community experienced in recent times.
Competing interests: No competing interests
Jason Luty makes several fundamental mistakes in his rather narrow interpretation of the recovery agenda. Firstly, this agenda is not about opiate substitution therapy versus abstinence. Yes, there is a target to discharge some people from treatment but there is also an acceptance that for some individuals recovery means being free of illicit drugs but maintained on a substitute. Secondly, the assumption that substitution therapy is evidence based has usually been based on substitution therapy versus detoxification to no treatment. In fact if we look closely at NTORS we will find that patients actually do better in rehabilitation, and there is even some evidence for cost effectiveness. Make no mistake, NTORS was all about proving a case for substitution therapy as a response to HIV/AIDS, it was not about improving the lots of drug users. Thirdly and perhaps most importantly, Luty admits that half of the patients on a script manage to stay opiate free. What about the other half? This is the group that should be targeted, not parked. We need to tease out whether these users want to be illicit opiate free. If they do not we need to ask hard questions about why we are prescribing for them and adding another powerful opiate into the mix. How does a script benefit patients who continue inject? Is it more risky to prescribe for this group?
In conclusion, I would suggest there is a place for opiate substitution therapy whether on a long or short term basis. There is no place for opiate supplementation. At it's best substitute treatment helps users achieve abstinence and turn their lives round. At it's worst, it colludes with addiction, maintaining our patients at the margins society unable to take that big step towards change and freedom from addiction.
Competing interests: No competing interests
Nutt's statement that horse-riding was more harmful than using Ecstasy was the one which lead to his downfall (or so I am lead to believe). Rather than diffuse the situation, the storm went from a canter to a gallop after he defended his statement, saying the costs to the NHS of injuries of riders who had fallen from their horses were little realised. Nor was it appreciated that riders who lost control of their horses on the roads were the cause of more than 100 serious accidents every year. Professor Nutt further stated, "It (horse-riding) is a popular activity, dangerous but addictive. I am told that many riders find it difficult to give up."
Notwithstanding such humorous quips, it is evident that the government were not willing to deal with a scientist who spoke his mind and remained true to himself at all times-the quality people most admired in Professor Nutt. Surely this is the hallmark of any 'independent' scientific advisor worth his salt? The government scored a spectacular own-goal in sacking Professor Nutt, as they sent out a message that advising scientists could not be truly independent at all, and would be whipped in to shape if necessary. A cautionary tail for other would-be scientific advisors of the future.
Competing interests: No competing interests
Dr. Luty scores a huge own goal in his statement regarding government saving money by promoting abstinent recovery. Abstinent recovery is a reality and does exist, it's just that many of his profession don't believe it. Here is a statement on real recovery which is abstinent based. I may remind him that heroin is a small part of the overall addiction world. By far is alcohol, the socially accepted drug of most addicts.
Our definition comprises the below elements.
Totally abstain from alcohol
Totally abstain from mind altering substances
Totally abstain from illicit drugs
Are not taking any prescription medication for addiction (for maintenance and detox) e.g. Subutex, Methadone, benzodiazepines etc.
We do not commit crime and live within the parameters of common law.
As individuals we have the tools to deal with life on life’s terms and know what action to take to avoid a lapse and indeed relapse.
Fully functioning, emotionally mature productive members of society.
We do not burden the public purse with issues which can be addressed through our personal recovery maintenance.
We follow principles of personal growth and change in our lives. (Whether this is through fellowships or by other means we live in real recovery.)
Competing interests: Rehabgrads believe in abstinent recovery from all mind altering drugs. Enabling service users to access Residential Rehabilitation where it is needed and sought.
Luty  has done a good service to both commissioners and service users by pointing to an embarrassing “Elephant in the Room” of government planning. What really is the purpose of addiction services?
Luty discusses therapy for people dependent on heroin: they have been the focus of the National Treatment Agency (NTA) ever since it began work. This week the rudderless NTA is absorbed into a new body, Public Health England (PHE). Just before PHE begins work, its brave chief executive has promised “we are as ready as we possibly can be and that the outstanding risks have been identified and are being tackled.”
The biggest risk to addiction services is therapeutic pessimism, and the negative consequence of commissioners feeling “am I bothered”? On 11 April 2013 there is a memorial service for a heroically optimistic doctor, Hamid Ghodse (1938-2012) who knew more about helping heroin users than anyone else. 25 years ago, when I first worked for Ghodse, the government priority for services was preventing the spread of HIV. The priority for the next government (which created NTA) was reducing the crime associated with funding a heroin habit. The economic priority for the present government is getting heroin users off benefits and costly health and social care.
Successful treatments are likely to be those where each patient’s goals are in alliance with their service. For example, Ghodse knew that mothers dependent on heroin who had infant children often stayed away from the Health Service. As a response, his imaginative mother and baby drug service was opened by Princess Diana in 1989. Other patients I met in London benefited from different services e.g. a day hospital for someone with co-morbid mental illness and drug dependence who had become very socially isolated, or residence in a drug-free therapeutic community for someone who wanted to become abstinent but had a long history of trauma and alienation.
While the department of health in 2013 talks up “choice”, heroin users seem rarely to get any choices but Hobson's Choice. Understanding the assets and liabilities (and deep longings) of patients would help plan more effective treatments. “Addiction” is more than a drug  and “addicts” are just as varied as the rest of the Public.
 Luty J. Promoting abstinence for drug users is about saving money not science. BMJ 2013; 346:f1481
 Selbie D. Friday message, 28 March 2013. Update from Public Health England.
 Caan W. Capitalizing on patients’ assets. Journal of Psychiatric & Mental Health Nursing 1995; 2: 115-116.
 Caan W. Defining addiction, with more humanity. Contemporary Social Science 2012; 7: 159-165.
Competing interests: Unpaid advisor to the East of England MUSE substance use group
While agreeing with Dr Luty on the need for accessible opioid maintenance treatments, he is unduly pessimistic regarding long-term abstinence. Good research shows that, as with tobacco and alcohol, about 4% of addicted individuals become abstinent each year, regardless of treatment (ref 1). By ten years over a third of opioid dependent citizens have achieved abstinence. The remainder are mostly on opioid maintenance treatment, one of the smallest yet most efficient parts of any health system, requiring little more than a GP and an experienced pharmacist. This saves lives and reduces many other negative aspects of addiction (ref 2).
Those who are denied appropriate treatment have a mortality rate up to 7 times higher than those in treatment (ref 3). This is especially important on prison release where automatic access to treatment should be the dual responsibility of the health and custodial systems.
The arbitrary rules of the UK NHS quoted by Dr Luty should not distract us since dependent pharmacotherapy patients are not fundamentally different from others with chronic conditions. New and unstable patients will require frequent reviews while others can be seen just a couple of times per year to ascertain progress and decide on any changes in doses, medication combinations and/or ancillary services.
Another disadvantage of the British system is that buprenorphine, the only evidence based alternative to methadone, is still not available in many health regions largely due to the high cost of this drug.
Opioid maintenance is not rocket science, yet for decades the UK had the twin problems of inadequate dose levels and almost non-existent formal dose supervision (ref 4). This so limited the positive outcomes that many now express doubts about the benefits of the treatment as it is used in the UK. Current and past leaders of the UK medical profession in the dependency field must take responsibility for these deficiencies, now causing politicians to dismantle an essential intervention which is implemented in almost every western country and now importantly in China.
Andrew Byrne ..
Ref 1 Thorley A. Longitudinal Studies of Drug Dependence. In: Drug Problems in Britain: A review of ten years. Eds: Edwards G, Busch C. 1981, Academic Press. p162
Ref 2 Mattick RP, Breen C, Kimber J, Davoli M. Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence (Cochrane Review) The Cochrane Library, Issue 1 (2005) Chichester, UK: John Wiley & Sons, Ltd
Ref 3 Peles E, Schreiber S, Adelson M. Opiate-Dependent Patients on a Waiting List for Methadone Maintenance Treatment Are at High Risk for Mortality Until Treatment Entry. J Addict Med 2013 Mar 20. [Epub ahead of print]
Ref 4 Strang J, Manning V, Mayet S, Ridge G, Best D, Sheridan J. Does prescribing for opiate addiction change after national guidelines? Methadone and buprenorphine prescribing to opiate addicts by general practitioners and hospital doctors in England, 1995–2005. Addiction 2007 102:761-770
Competing interests: Dr Byrne runs a private addiction out-patient clinic.