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Public Health England.
Public Health England, 2013.
Agency responsible for addiction treatment in England argues that efforts to put recovery at its heart are paying off in the form of patients successfully completing treatment and not having to return, but warns that the older caseload is getting harder to move on. One concern: is treatment being de-individualised to generate a 'good news' story?
Summary Within its brief to protect and improve the nation's health and address inequalities, Public Health England aims to promote addiction treatment by offering support, information and practical assistance to the local authorities with executive responsibility for local treatment systems. This report documents the nation's progress in respect of the treatment of adults (over 18) receiving treatment for problems related to their use of illegal drugs; another report deals with the treatment of alcohol-related problems. This account draws on the featured report and the data on which it was based, derived from the National Drug Treatment Monitoring System.
Against a backdrop of falling use of illicit drugs in the general population, the number of people in structured treatment Structured drug treatment follows assessment and is delivered according to a care plan, with clear goals, which are regularly reviewed with the client. for drug problems in England fell by 2% to 193,575, slightly deepening the fall since 2008/09 chart. Among these were 69,247 patients who started treatment in 2012/13, either for the first time or having relapsed after previous treatment – again, slightly deepening the fall since 2008/09.
The drop in treatment starts reflects a continuing fall in the numbers starting treatment primarily for problems related to heroin and/or crack cocaine, down from 64,288 in 2005/06 to 45,739. In turn this was largely due to a sharp decrease in the number of newly presenting opiate users aged 18–24, from 11,309 in 2005/06 to 3536 in 2012/13; among newly presenting clients in this age group, the proportion whose problems primarily related to opiate use dropped from 61% in 2005/06 to 29% in 2012/13.
In contrast, the number of people starting treatment for problems relating to cannabis use continued to rise, from around 7500 in 2005/06 and 2006/07 to 11,280 this year. Many more people are also seeking treatment in relation to their use of new psychoactive substances Specifically GHB/GBL, ketamine, ecstasy, methamphetamine or mephedrone. or 'legal highs' and certain 'club' drugs. Nevertheless they accounted for just 5% of new treatment journeys this year, and recovery rates for these users remain good. The number with problems primarily relating to cocaine powder (ie, not crack) was 7372, having peaked in 2008/09 at 8522.
The upshot of these trends is a dramatically changed drug profile of treatment starters. In 2005/06 there were almost three times the number of heroin users starting treatment for the very first time compared to all other users (47,811 versus 16,778). Now the number of other users entirely new to treatment outstrips heroin users by two to one (16,220 versus 8318).
Another trend to emerge in recent years is that people new or returning to treatment are on average getting older. Totalling 38,485 in 2005/06, by 2012/13 the number of treatment starters aged under 30 had fallen to 25,027. In contrast, the number aged over 40 rose from 12,678 to 17,148; these now constitute 25% of all treatment starters compared to 15% in 2005/06. Trends in treatment starts mean the treatment population is gradually ageing. In 2005/06, 32,406 people aged 40 and above were in treatment at some time during the year, 18% of the total; by 2012/13 these figures had risen to 65,339 and 34%.
Waiting times have improved a little; 98% of referrals waited under three weeks for their first appointment, and the average waiting time was five days.
Before treatment setting/modality codes changed on 1 November 2012, at least 79% of all patients in treatment (new or continuing) were recorded as being prescribed medications, usually methadone for the treatment of opiate addiction. The coding system changed from 1 November 2012, after which 61% of patients were recorded as having started a prescribing intervention. In 2012/13, a quarter of all patients being prescribed medications and the same proportion of opiate users (representing just under a fifth of all patients) had been in this treatment without a break for at least five years, about a third for less than a year. The proportion of people in treatment going into residential rehabilitation has remained static at around 2–3%.
The proportion of patients who had been in treatment for at least 12 weeks or completed free of dependence has remained at 94% since 2011/12 and there has been a general upward trend from 82% in 2005/06.
In 2012/13, 29,025 patients 'successfully completed' their treatment – leaving free of dependence, judged no longer in need of treatment, and not using heroin or crack cocaine. Nearly three quarters were not using any illegal drug. At 15%, the proportion of patients successfully completing during 2012/13 was the same as the previous year but a considerable advance However, in 2009 a new discharge coding system was introduced which clarified the coding of referrals within the treatment system, and tightened the way 'treatment completed' was recorded. These changes mean it is not possible to directly compare treatment exit data from 2009/10 with previous years. on the 6–7% recorded in 2005/06 and 2006/07. Another 18,253 patients dropped out or otherwise left treatment without completing it, 9% of all patients in treatment that year, a proportion which has dropped from 21% in 2005/06.
Because it often takes people more than a year to recover from their drug problems, we need to take a longer view when judging the success of drug services. Adding data for 2012/13 to the figures for previous years reveals that since 2005, 31% of the 390,883 people who had come into treatment had successfully completed it and were no longer in treatment at the end of 2012/13; 36% had left without completing; and 32% were still or back in treatment, among whom were 12% who had remained in treatment without an appreciable break. These figures include patients who started treatment before 2005/06. A more contemporary analysis focuses on the 304,811 who entered treatment for the first time since April 2005, of whom 56% were treated for their use of opiate-type drugs like heroin. By the end of 2012/13, 34% were no longer in treatment after having successfully completed, 39% after leaving without successfully completing, and 27% were still in treatment, either because they had stayed continuously or left and returned.
Drug treatment services in England continue to do well. They are getting the right people into treatment and helping many thousands recover. But they face increasingly apparent and urgent challenges. The treatment population is shrinking, but also getting tougher to treat.
The key issue is that many have been with treatment services a long time and are finding it difficult to move on. Local services, backed by the national support system, need to continue and in some cases intensify their efforts to help them make a sustained recovery from dependence – not an easy task. Many are older with entrenched problems and failing health. So as well as supporting them in their recovery, services need to address their health problems and help them stay safe; for many treatment is a source of stability which gives structure to their lives. Services also need to remain watchful and respond effectively to the needs of the wider treatment population, such as those who need help with new substances and prescription or over-the-counter medicines. More detailed commentary below.
The total number of people in drug treatment in England has been falling since 2008/09 because fewer have been starting new treatment journeys, and more have successfully completed and not returned. Explanations include the recent shift in focus from ensuring that all those who need treatment get it quickly, to helping those in the system recover and leave. The decline in heroin and crack use has also had a big impact. Services in England developed to respond to the many people who started using these drugs in the 1980s and 1990s, but now these drugs have fallen out of favour among young people, so we see far fewer new cases. The result is that the pool of heroin and crack users is gradually shrinking.
A quarter of people in treatment for opiate problems have been in substitute prescribing (generally methadone) for five years or more, reflecting the entrenched nature of heroin addiction, the benefits of being on a prescription, and an ageing population finding it difficult to overcome dependence and experiencing wider health problems. It is getting harder to help this group, and this has begun to show in the successful completion figures.
Younger people today are much more likely than in the past to enter drug treatment for problems with cannabis, even though cannabis use among the general population is down. This may be because treatment services have in recent years become much more aware of and open to people who are running into trouble with the drug, and because the fewer users are using stronger strains more often.
New drugs have surfaced (such as mephedrone), but not with anywhere near the impact of heroin in the 1980s and 1990s. Still, new substances and new patterns of use are a concern, and the fast pace of change makes it difficult to predict trends or to develop knowledge about the harm these drugs might cause. There is also the problem of addiction to prescription and over-the-counter medicines, which specialist treatment has an important part to play in tackling.
commentary If we accept successful completion of treatment as (within these statistics) the closest indicator of successful treatment, the year by year figures tell a tale of an improving treatment system in England, the success rate more than doubling from 6% to 15% over seven years.
Extending these within-year figures, the eight-year analysis indicates that since April 2005, 31% of all patients had successfully completed and were not back in treatment at the end of 2012/13, a 'success' rate of nearly a third. The other side of the coin is that two thirds remained in need of treatment or beyond its protection without having successfully completed. Many ( below) will actually be successes, having left and done well without completing, or having stabilised in treatment. The clearest 'failures' are the 20% of patients who had been in treatment before but had returned and were still in treatment at the end of 2012/13, presumably because their prior treatment had not worked and/or they had relapsed. Though their previous treatment was followed by a return to problem drug use, even for these patients, re-engagement in treatment can be seen as a positive event.
If successful completion is that important, also important is understanding exactly what it means. For the recording system, 'successfully completing' treatment means that as reported by the service from which the patient last exits, they are no longer seen as requiring structured drug treatment, and have left treatment (not just that service, but the system as a whole) no longer dependent on any drug, and not using opiates or crack cocaine (1 2). They may be using other illicit drugs in a non-dependent manner (though few are recorded as doing so) and may be drinking and smoking to any degree.
This system is critically dependent on the integrity and accuracy with which treatment services record the status of their departing patients. In 2007/08 the BBC exposed the tiny proportion of patients who within a single year left treatment drug-free, intensifying a national policy emphasis on successful completion. Since then commissioners and services have been under reputational pressure to produce more successful completions, and in recent years, under financial pressure too. Allegations have surfaced that this has led services to bend the figures or to pressure patients to leave treatment or to discharge them before they are ready. Some service contracts now include a financially backed target for treatment exits. If exits are indeed being arranged to meet national or local needs and ambitions rather than those of the patient, this de-individualisation of treatment would make the increased completion rate less of a 'good news' story.
Year-by-year statistics can only show that someone was in treatment that year, and if they left, whether they returned the same year. The eight-year analysis adds a further rider to the indicator of success – that whenever the patient started treatment and whenever they successfully completed, they should not be in treatment at the end of the period covered by the analysis, 31 March 2013.
This analysis confounds the passage of time over which treatment success rates may have improved, with the time the patient had to recover or relapse. Patients entering treatment in for example 2005/06 had eight years, those entering in 2012/13, less than a year. More informative is what proportion of patients succeed over a given time period, and whether this has improved in recent years. It can be calculated that five years later, 35% of patients new to treatment in 2007/08 were no longer in treatment having successfully completed. Another 42% had left without completing; the remaining 23% were still or back in treatment. Corresponding figures for the five years after patients started treatment in 2005/06 were 20%, 42%, and 38%. If successful completion and not being in treatment five years later is a proxy for successful treatment, then the success rate increased from 20% for patients new to treatment in 2005/06, to 35% for those who started two years later.
The same analysis shows how few treatment starters are totally new to treatment, a figure which has fallen steadily from 64,589 in 2005/06 to 24,538 in 2012/13. It means that the great majority of the 193,575 patients seen in 2012/13 were continuing in or returning to treatment. In turn that helps explain why despite the changing drug profile of patients (re)entering treatment, the proportion of the entire treatment population whose problems primarily related to opiates (with or without crack) has remained at around 80% since 2005/06. These primarily heroin-addicted patients are the ones who stay in or relapse and have to return to treatment; 42% did so after entering treatment between 2005/06 and 2012/13 compared to 8% of patients not treated for opiate use. The 'stickiness' of the heroin-addicted patients also helps explain why since 2005/06 almost exactly a half of all patients in treatment were being prescribed drugs such as methadone, in turn probably partly the cause of their retention or willingness to return to treatment.
The argument that increasing numbers of successful completions is evidence of increasingly successful treatment rests partly on an analysis of patients leaving treatment for drug problems in 2005/06. Over the next four years, 57% who left having successfully completed avoided being officially recorded as problematic users of illegal drugs, neither being picked up by criminal justice system nets intended to identify problem drug users, nor returning to treatment on their own initiatives. This record of 57% seemingly staying recovered from their dependence contrasted with 43% among patients who left without having successfully completed treatment. The 14% difference of is appreciable, but not as large as would be expected if successful completion correlated strongly with successful treatment in terms of lasting recovery. Nevertheless it is enough to justify conclusions based on the assumption that successful completion is a better outcome than patients leaving treatment before the service considers them free of dependence and/or use of heroin or crack cocaine.
Whether successful completion is also a better outcome in terms of crime and health than staying in treatment – the usual situation within each year – is less certain. In terms of reduced convictions and presumably reduced crimes, another report from National Treatment Agency for Substance Misuse records that for patients convicted in the two years before starting treatment, the greatest reductions were among those continuously in treatment for the next two years, though successful treatment leavers were not far behind (47% v. 41%). However, these figures combine big differences in the types of patients who stay and leave treatment early. When the focus was narrowed to opiate/crack users, among whom successful completers and retained patients had a virtually identical pre-treatment conviction rate, the gap widened to 10% (46% v. 36%).
Thanks for their comments on this entry in draft to Tim Murray of Public Health England. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 08 January 2014. First uploaded 14 November 2013
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STUDY 2014 Drug treatment in England 2013–14
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DOCUMENT 2012 Substance misuse among young people 2011–12
DOCUMENT 2011 Substance misuse among young people: 2010–11