Putting Public Health First
Download the covering letter and statement as a pdf
Dear Lord Henley
Please find attached a public statement that has been issued by the UK Harm Reduction Association, the UK Recovery Federation and the National Users Network, in response to the document published by the Home Office on 13 March 2012 titled “Putting Full Recovery First - the Recovery Roadmap”.
This statement has been supported by a number of organisations and individuals who work or are interested in the drug treatment field. Many of the signatories and our organisations are concerned that the Home Office document ignores the evidence base for good treatment interventions and will have a negative impact on those accessing services.
The UK has long been seen as a leader in the field of drug treatment and harm reduction. We believe it is important that we continue this excellent work and we would welcome the opportunity to meet with you to discuss our concerns.
Alistair Sinclair, UK Recovery Federation
Statement attached below
Putting Public Health First
In March this year, the Coalition Government released a document entitled ‘Putting Full Recovery First’, outlining a “roadmap for building a new treatment system based on recovery”.1 It describes “a new agenda” focused on “full independence from any chemical” (which will be main measure for ‘Payment by Results’ in drug treatment). This document is intended to influence services and commissioners, but it ignores decades of evidence in drug treatment and the core principles that underpin recovery within both the substance use and mental health fields.2 It will do more harm than good: increasing drug-related harm (including HIV transmission and overdose) and reducing levels of engagement with treatment services. People living stable, fulfilling lives assisted by opioid substitution therapy (OST) will be placed in jeopardy, and scarce public funds will be wasted by undermining established, evidence-based interventions. There has been minimal input into this Roadmap from people who use drug services or those who provide drug treatment. Given the serious concerns that we outline below, we call for all stakeholders to be given the opportunity to contribute to a more open and inclusive policy.
Predetermined treatment goals are arbitrary, unethical and ineffective:
Some people enter treatment to become abstinent — others may not be able or willing to reach this goal. Some people benefit from long-term OST3 4 5 — others from abstinence-based programmes.6 Some people’s problems stem from the drug(s) that they use — others’ from patterns or methods of drug use,7 8 or from homelessness, unemployment or a history of abuse. Imposing a ‘one-size-fits-all’ abstinence goal upon this diverse population is dangerous, legally problematic and may contravene medical ethics. The Government’s 2010 Drug Strategy described ‘recovery’ as “an individual, person-centred journey”9, i.e. it can mean different things to different people, and many different pathways exist (including medication assisted recovery10). Services must be client-led and empowering, not predetermined in a policy document. This is not “fatalism” (as the Roadmapstates) but an approach based on evidence, experience and pragmatism.
The Roadmap wilfully ignores evidence and expert guidance:
Putting ‘full recovery’ first implies all other goals — including reduced HIV transmission and overdoses — are secondary. Yet interventions such as needle and syringe programmes (NSP) and OST are among the most proven, effective public health responses available. Numerous scientific reviews have concluded in their favour in the UK11 12 and internationally.13 14 15 Methadone, buprenorphine and naloxone are World Health Organization “Essential Medicines”.16The Roadmap acknowledges the “evidence base underpinning effective treatment interventions”, yet simultaneously ignores it. For example, OST is cast aside in search of “new evidence” for new approaches (for which the Roadmap includes no provisions for rigorous evaluation).
The Roadmap represents a threat to public healthin the UK:
The1980s Conservative Government embraced harm reduction — a bold and pragmatic move that averted a major public health crisis, as we know from looking at how HIV spread in countries that were slower to respond (such as the USA, Spain and Russia).17 The Roadmap, however, ignores decades of evidence and states that: “It is self-evident that the best protection against blood borne viruses is full recovery”. A person who has achieved ‘full recovery’ is free from drug-related risks as long as they remain abstinent. But relapse is a reality for many people.18 The risk of blood-borne viruses returns if injecting resumes, and people who relapse face heightened risks of overdose if support (and take-home naloxone19) is not provided.20 The Roadmap states that “everybody deserves a second chance”, but ‘recovery’ means much more than just abstinence.
Recent experiences in Greece demonstrate the danger of overlooking evidence-based responses. HIV incidence among people who inject drugs has risen from between 9 and 16 cases annually in the preceding five years to 190 cases in 2011 alone — an upsurge associated with the economic crisis and the absence of comprehensive prevention programmes.21 The Coalition Government is gambling with lives by focusing on a singular, narrow vision of ‘full recovery’ rather than the more open and balanced approach described in their Drug Strategy.22
The Roadmap devalues evidence-based treatment and threatens patient wellbeing:
The Roadmap claims it will “deliver much better value for taxpayers’ money in the short and longer terms as ultimately payment will be made for full recovery only”. This statement trivialises the complex nature of drug dependence and the common co-morbidities.23 24 Financial incentives for ‘full recovery’ could encourage services to exclude those unlikely to achieve this goal. Abuse and stigma risk becoming commonplace, exacerbated by withdrawn payments for ‘recovered’ clients who relapse within a year. Offering insufficient rewards for proven public health services such as NSP, OST and overdose prevention will damage the population the Roadmap aims to help.
Evidence and experience clearly demonstrate that OST can effectively tackle dependence,25 prevent HIV26 and hepatitis C,27 reduce illicit drug use,28 29 prevent overdoses,30 ensure retention in treatment,31 save lives,32 reduce crime and re-offending,33 34 and support employment,35 36 housing status,37 38 mental and physical wellbeing,39 and personal relationships.40 In some cases, OST in isolation has failed to meet wider psychosocial needs, and these programmes must adapt, support a more inclusive goal of ‘recovery’, and constantly improve like any other health service. However, the Roadmap implies that even when OST is working for an individual, this is still not good enough. Successful treatments will be withdrawn based on the Government’s value judgements, and this threatens the autonomy of medical personnel. It also contradicts the evidence and puts patients at unnecessary risk — research shows that withdrawal under duress is ineffective and can increase illicit drug use.41 42 43
The Roadmap will waste scarce resources:
The Roadmap bypassed public consultation, yet carries logos from eight governmental departments. It lacks detailed guidance on how services can achieve the prescribed goals, and omits any financial analysis: there are around 200,000 adults in treatment,44 yet how they will all be supported (and funded) toward ‘full recovery’ remains unaddressed. Cost effectiveness is a major concern, as the effectiveness of psychosocial treatments alone remains unproven.45 Relapse rates could rise if abstinence is forced upon people46 and withdrawing successful prescriptions will undermine progress toward employment etc.47 Health costs associated with overdose and infections may also spiral. By contrast, existing UK drug treatment provides around £2.50 in benefits to society for every £1 spent,48 and NSP has been found to return AUS$5 in healthcare savings for every AUS$1.49
In order to protect and improve the lives of people who use drugs, their families and their communities, we strongly oppose a Roadmap that is devoid of evidence to support the changes and ignores the evidence against. It neglects decades of success and best practice in harm reduction and recovery-orientated drug treatment. The ideologically-driven hierarchy (with ‘full recovery’ at the top and any other achievement marked as inferior) profoundly misunderstands the lives of many people who use drugs, the complexity of their problems, and the services that work with them. We therefore call upon the Government to reconsider the approach described in the Roadmap, to consult with all of the relevant stakeholders, and to develop a more rational, meaningful policy document.
We the undersigned look forward to your response.
1 Putting Full Recovery First. London: Department of Health, Department of Work and Pensions, Ministry of Justice, Department for Communities and Local Government, HM Treasury, Cabinet Office, Department for Education & Home Office; 2010.
2 Sheedy CK & Whitter M. Guiding Principles and Elements of Recovery-Oriented Systems of Care: What Do We Know From the Research? Rockville, MD: Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration; 2009.
3 Mattick RP, Breen C, Kimber J & DavoliM. Methadone Maintenance Therapy Versus No Opioid Replacement Therapy for Opioid Dependence. Cochrane Database of Systematic Reviews, 2009; Issue 3: CD002209.
4 UNODC’s Response for Prevention of HIV Among Drug Users in South Asia Through Opioid Substitution Treatment (OST): Concepts of Opioid Substitution Treatment (OST). 2007. Available from: http://www.unodc.org/india/ost_interventions_concepts.html
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12 Needle and Syringe Programmes: Providing People who Inject Drugs with Injecting Equipment: NICE Public Health Guidance 18. London: National Institute for Health and Clinical Excellence; 2009.
13 Effectiveness of Drug Dependence Treatment in Preventing HIV Among Injecting Drug Users. Geneva: World Health Organization; 2005.
14 Gowing L, Farrell MF, Bornemann R, Sullivan LE & Ali R. Oral Substitution Treatment of Injecting Opioid Users for Prevention of HIV Infection. Cochrane Database of Systematic Reviews, 2011; Issue 8: CD004145.
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18 Magura S&Rosenblum A. Leaving Methadone Treatment: Lessons Learned, Lessons Forgotten, Lessons Ignored. Mount Sinai Journal of Medicine, 2001; 68: 62–74.
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22 Drug Strategy 2010: Reducing Demand, Restricting Supply, Building Recovery:Supporting People to Live a Drug Free Life. London: HM Government; 2010.
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26 Gowing L, Farrell MF, Bornemann R, Sullivan LE & Ali R. Oral Substitution Treatment of Injecting Opioid Users for Prevention of HIV Infection. Cochrane Database of Systematic Reviews, 2011; Issue 8: CD004145.
27 TurnerKME, Hutchinson S, Vickerman P, HopeV, CraineN, et al. The impact of needle and syringe provision andopiate substitution therapy on the incidence of hepatitis C virus in injecting drug users: pooling of UK evidence. Addiction, 2011; 106(11): 1978–1988.
28 Mattick RP, Breen C, Kimber J & Davoli M. Methadone Maintenance Therapy Versus No Opioid Replacement Therapy for Opioid Dependence. Cochrane Database of Systematic Reviews, 2009; Issue 3: CD002209.
29 Ward J, Mattick RP, Hall W. The Effectiveness of Methadone Maintenance Treatment: An Overview. Drug and Alcohol Review, 2009; 13: 327–336.
30 Successful Strategies in Addressing Opioid Overdose Deaths. Rockville, MD: Center for Substance Abuse Treatment, 2010.
31 Mattick RP, Breen C, Kimber J & Davoli M. Methadone Maintenance Therapy Versus No Opioid Replacement Therapy for Opioid Dependence. Cochrane Database of Systematic Reviews, 2009; Issue 3: CD002209.
32 Zanis DA & Woody GE. One-year Mortality Rates Following Methadone Treatment Discharge. Drug and Alcohol Dependence, 1998; 52: 257–260.
33 Lind B, Chen S, Weatherburn D, Mattick R. The Effectiveness of Methadone Maintenance Treatment in Controlling Crime: An Australian Aggregate-Level Analysis. Journal of Criminology, 2005; 45: 201–211.
34 Turnbull PJ, Edmunds M & Hough M. Drug Treatment and Testing Orders: Final Evaluation Report. London: Home Office Research, Development and Statistics Directorate, 2000.
35 UNODC’s Response for Prevention of HIV Among Drug Users in South Asia Through Opioid Substitution Treatment (OST): Concepts of Opioid Substitution Treatment (OST). 2007. Available from: http://www.unodc.org/india/ost_interventions_concepts.html
36 Powers KI& Anglin MD. Cumulative Versus Stabilizing Effects of Methadone Maintenance: A Quasi-ExperimentalStudy Using Longitudinal Self-Report Data. Evaluation Review, 1993;17:243–270.
37 Best D, Man L-H, Zador D, Darke S, Bird S, Strang J & Ashton M. Overdosing on Opiates. Drugs and Alcohol Findings, 2001; 5: 4–18.
38 Injectable Heroin (and Injectable Methadone): Potential Roles in Drug Treatment: Full Guidance Report. London: National Treatment Agency for Substance Misuse, 2003.
39 Jones A, Donmall M, Millar T, Moody A, Weston S, Anderson T, Gittins M, Abeywardana V & D’Souza J. The Drug Treatment Outcomes Research Study (DTORS): Final Outcomes Report. London: Home Office, 2009.
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46 Magura S & Rosenblum A. Leaving Methadone Treatment: Lessons Learned, Lessons Forgotten, Lessons Ignored. Mount Sinai Journal of Medicine, 2001; 68: 62–74.
47 Powers KI & Anglin MD. Cumulative Versus Stabilizing Effects of Methadone Maintenance: A Quasi-Experimental Study Using Longitudinal Self-Report Data. Evaluation Review, 1993; 17: 243–270.
48 Drug Treatment in England: The Road to Recovery. London: National Treatment Agency for Substance Misuse; 2012.
49 Return on Investment 2: Evaluating the Cost-Effectiveness of Needle and Syringe Programs inAustralia. Sydney:Australian Government, Department of Health and Ageing, National Centrein HIV Epidemiology and Clinical Research, 2009.