Yoof of today!

We definitely seem to have entered the silly season in the run up to Christmas. In the past week I have received several inquiries from the press who all seem to think that I must have some kind of crystal ball or arcane knowledge about "young people". I have been asked about young people and AA/NA - “is it trendy for young people to go to 12 step meetings now that Lindsay Lohan has admitted that she is going to meetings?”

Who cares if it is “trendy” or not, they are missing the point – its about saving lives, not fashion! Is coronary care trendy? Are A & E departments trendy? I have to ask myself what kind of rarefied atmosphere do these guys live in? Have they put something in the water in Wapping?

Lindsay Lohan is living in California, I live in South Yorkshire. Young people in California do lots of things that haven't caught on over here – surfing for one – and there are huge cultural differences in the way addiction and recovery are viewed over here and there.

The end result is that young people do go to AA/NA meetings in the US – especially California, while over here in the main they don't.

Most “addicts” seem to turn up in NA at around the age of 30 and it's around 40 for AA. There are of course exceptions to this rule.

I believe that one of the causes of this is the marked reluctance on the part of treatment providers in the UK to properly diagnose alcohol and other drug use in young people.

In the main the attitude seems to be that alcohol and other drug use is symptomatic of developmental problems rather than a condition that requires proper diagnosis and treatment in it's own right. In fact there are very few services in the UK providing proper addiction treatment for “young people”. Our very politically correct practitioners prefer to treat the age rather than the disease.

Then I would say that wouldn't I? I am a grumpy old addict after all!

Whitehall's "Spinball" Drug of Choice!

There were two very interesting, yet contradictory, stories in the press this weekend regarding Methadone:

The Scottish press, in the form of Scotland on Sunday and The Scotsman, ran a story on Professor Neil McKeganey's research (from Glasgow University) which shows that only 3.4 percent of drug users who were prescribed Methadone were “drug-free” after 3 years as opposed to 29 percent of those who went into residential treatment.

Other differences were just as startling:

Of those who received Methadone:

• 29 percent were in employment or education.
• 47 percent said that they “felt better”.
• 91 percent admitted to committing crimes.

Of those who took the abstinence route:

• 59 percent were in employment or education.
• 79 percent said that they “felt better”.
• 13 percent admitted to committing crimes.

Professor McKeganey's research seemingly shows that Methadone “treatment” is only marginally better than no treatment at all.

There are apparently around 20,000 addicts receiving Methadone in Scotland.

Meanwhile in England the Sunday Mirror reported that 84,583 people were in treatment for Heroin addiction (in England). Caroline Flint MP (now the Health Minister, previously the Drugs Minister) reported that the figure had almost doubled over the past 2 years and that this was a sign that the government's drug strategy was a success.

It also reported “experts” as claiming that the true number of Heroin addicts could be 120,000 because many users “weren't receiving medical help” . We reckon that the real figure is likely to be at least double this – say 250,000?

Um........ We also note that the report talks about “medical help” - effectively prescribed Methadone. The article then went on to report that drug related crime had fallen by 16 percent from April 2004 to March 2006. It then trots out the old statement that “for every £1 spent on treatment £9.50 is saved in crime and health costs”.

Am I the only one to sense a contradiction here?

Either Scottish Addicts are very different from English ones (They are not – I have worked with both) or Scottish professionals are less competent than their English counterparts ( again we know that they are not) or something is wrong with the figures! Especially so when Caroline Flint's figures don't even seem to relly match up with those from the National Treatment Agency which last month reported 181,000 people in treatment for drug use! ( If 84,000 are Heroin addicts what are the other 97,000 doing?)

Could it actually be that someone, somewhere – perhaps not a million miles away from Central London – is massaging the figures?

If I have to chose between the 2 stories I would have to say that in my experience Professor McKeganey is the one that we should be believing! But Scotland and Glasgow are a very, very long way from Whitehall (unlike Baghdad and Kabul) so we very much doubt that anyone will take any notice whatsoever of this research.

"Evidence based Research" only counts when it says what they want to hear!

Lies, Damn Lies and Statistics!

Just recently the National Treatment Agency for Substance Misuse put out a press statement - see the NTA website for details - trumpeting the fact that a key government target (doubling the number of people in drug treatment) had been achieved 2 years early.

There than followed a lot of detail about substances used, retention rates, ethnic groups etc. Important as this information is (or might be - if it was ever used for anything!) I then spent a very frustrating 30 minutes looking for anything remotely resembling outcome data. There wasn't any.

I finally went back to the NTA website and found another report released on the same day giving outcomes for the year before. It turns out that for the year 2004/5:

• 160,453 clients received 238,149 episodes of "structured care". (About 1.48 treatment episodes per individual!)
• Opiate dependency accounted for 75% of presenting clients. This was comprised of Heroin (64%) and Methadone (8%) and other (3%).
• 57% of clients remained in treatment for 12 weeks or more. 52% of clients received treatment described as "prescribing modalities" and there was apparently an increased likelihood of these clients being retained in treatment. In other words we are more likely to retain opiate addicts in treatment if we give them drugs! Now there is a suprise!
• Of those individuals "discharged" from treatment during the year 30% had successfully completed treatment. However when one looks at this 30% it turns out that only 6% (5,759 treatment episodes - not individials - are shown as being "Completed Drug Free". (You can be "drug free in the UK and drink 2 bottles of spirits a day - alcohol doesn't count!) 11 out of the 30% "successfully completing treatment" were "referred on" - in other words the individuals had not completed treatment at all! As for the other 13% who "successfully completed treatment" without being drug free I can only assume that they "successfully completed treatment" still using drugs!

A large part of the paper is about "factors associated with retention and succesful discharge". While I agree that the study of such factors is important this report makes comments like: "The proportion of episodes which were successfully discharged was greatest for those with Chinese clients (40%), whereas only 20% of those episodes where the client was Bangladeshi were successfully discharged". The numbers of Chinese and Bangladeshi clients "successfully discharged" were 29 and 143 respectively. I personally believe that making sweeping assertions about treatment outcomes based on samples this small is unjustifiable.

How many agencies (let alone non-english speaking workers) worked with these 2 groups? With numbers this small I would need convincing that the differences do not have more to do with the effectiveness of the agencies concerned, or perhaps even the effectiveness of a few workers, rather than the client's ethnicity! That the UK government bases it's "evidence based approach" to drugs treatment on such dubious logic which resembles an O-Level project rather than any real science is alarming! Where are the controls?

Lest I get so carried away here that I forget the point of all this - in the year concerned £457 million was spent on drug treatment (ignoring the money spent in prisons) and in England at least there is only evidence that 5,759 episodes of treatment ended with the client being discharged drug free.

That's £79,354 each! The total money spent could have bought something like 100,000 individuals for 13 weeks residential treatment in South Africa- yes, South Africa, and I am pretty sure that we could reasonably expect perhaps 50,000 of those individuals to have "Successfully completed treatment drug free".

Why do we let the NTA trumpet such appaling outcomes as some sort of triumph? It's actually more like a cause for despair!

Evidence Based Treatment

Evidence based treatment.... how often do we hear the phrase and what does it actually mean? It is supposed to mean that treatment is based on "what works" and that "what works" has been scientifically validated by research. However.....

Here in the UK we consistently ignore evidence that does not suit the political agenda. There is a wealth of research on the effects of addiction on the brain - using various brain imaging techniques - that demonstrates that the effects that drugs have on the brain and which show that the human brain does not show signs of recovery until a considerable period of abstinence has passed. Without going into a small book this research has considerable imlications for the treatment of chemical dependency. Walk into 100 or so alcohol and/or drug agencies up and down the country and ask if any of the staff are even aware of this research and you will find not.

This week an American psychiatrist was quoted as saying that the brains of compulsive gamblers also show similar abnormal scans and it is also a known fact that Naltrexone has been researched in the US as a potential treatment for compulsive gambling.

We also know that there is a distinct correlation between the availability of "addictive" substances and behaviours and the number of people exhibiting problems. Do we take all this evidence into acount? Do we hell - it just doesn't suit the governments agenda! Lets roll out 24 hour drinking and loads of casinos. Then act suprised when the number of people with alcohol and gambling related problems goes up! It will, the all the evidence predicts that it will - but we will ignore the evidence when it doesn't suit us!

Consider the so called "assessment" of individuals with alcohol and other drug related problems. There is a wealth of evidence that shows that there is substance use, substance abuse and substance dependency. The evidence also shows that these are distinct conditions with distinct needs in terms of treatment. Do all alcohol and drug services then actually sit down and diagnose which of these groups an individual falls into? No most do not, and consequently most treatment is inapropriate not to mention ineffective. Why is this? Because dependency requires intensive skilled (and often residential) treatment and the system is generally speaking not geared up to provide this.

It is easier for services to train staff to deliver MET or SFBT (it requires a short 3 day course in many peoples eyes!) than it is to train staff for the year or so required to deliver abstinence based services.

Don't get me wrong - I have nothing against Motivational Enhancement Therapy or Solution Focussed Brief Therapy - with the right individuals at the right time there is no doubt of it's effeciveness. For the rest of the client group however is a sentence to failure and dissilusionment with treatment.

Lets carry on then, blame the clients when treastment fails and concentrate on what is usually economics rather than the real evidence!