Drug and Alcohol Findings home page. Opens new window Effectiveness Bank bulletin 24 November 2014

The entries below are our accounts of documents collected by Drug and Alcohol Findings as relevant to improving outcomes from drug or alcohol interventions in the UK. The original documents were not published by Findings; click on the Titles to obtain copies. Free reprints may also be available from the authors. If displayed, click prepared e-mail to adapt the pre-prepared e-mail message or compose your own message. The Summary is intended to convey the findings and views expressed in the document. Below may be a commentary from Drug and Alcohol Findings.


Features the twin planks of drug harm reduction. Methadone maintenance – UK advisers clash with government minister over keeping patients in treatment, and from Norway, why retention is so important. Needle exchange – how misinterpreted early findings from Vancouver clouded its reputation. Final entry compellingly describes the real world challenges of introducing a new therapy programme.

‘Parking’ not the issue with methadone in the UK ...

Strive to retain ‘difficult’ methadone patients ...

How restricted syringe/needle supply let HIV spread in Vancouver ...

New therapy implementation will fail unless tailored to the organisation ...

Time limiting opioid substitution therapy.

Advisory Council on the Misuse of Drugs.
[UK] Advisory Council on the Misuse of Drugs, 2014.

Rather than being ‘parked’ on methadone, generally Britain’s heroin-addicted patients leave too soon to fully benefit, argue official government advisers on drug policy. Their report unambiguously countered concerns within the current UK government over methadone maintenance.

Summary The Advisory Council on the Misuse of Drugs is the official advisory body to the UK government on matters pertaining to the Misuse of Drugs Act 1971. The featured report is their response to a request for advice to the UK government’s ministerial-level drug policy committee on:
• whether the evidence supports the case for time-limiting opioid substitution therapy [such as methadone maintenance]; and if so, what would be a suitable time period and what would the risks and benefits be?
• additionally, if this is not the case, how can continuing opioid substitution therapy be optimised in order to maximise outcomes for service users?

The report notes that in 2011/12 in England, 197,110 patients had been treated for drug problems, including 159,542 for heroin dependence of whom 146,100 were in opioid substitution therapy. In the same year another 2871 patients were in opioid substitution therapy in Northern Ireland and Wales. Latest data for Scotland showed 22,224 in opioid substitution therapy in 2007/08. The substitution treatment population in England is an ageing, older cohort, often unemployed for many years and with long-term health and social problems.

Main findings

How long do patients need to be in opioid substitution therapy to benefit?

International research evidence indicates that longer treatment periods are associated with improved outcomes (including reduced use of other opioids and reduced criminal activity), while short-term methadone maintenance is associated with poorer outcomes. A US study which followed up methadone patients for 30 years found that the 40% who had achieved stable remission had been on methadone for five to eight years. Some US authors argue that the minimum time to achieve better and sustained benefits is a year.

How long is it desirable to be in opioid substitution therapy?

Studies find that patients have a range of opinions on whether they are maintained on opioid substitutes for too long. A recent study of 30 heroin users in treatment in England found all wanted to be free from heroin and from prescribed substitute medicines, and often they were impatient with the detoxification process. Some reduced their doses of substitute medication faster than prescribers recommended, often resulting in cross-addiction, relapse and slower recovery attempts. The authors concluded that recovery-oriented treatment can prompt heroin users prematurely into detoxification and abstinence programmes with negative consequences, and that the experiential knowledge of heroin users who have personally attempted recovery is a crucial resource.

Length of opioid substitution therapy in the UK

No current data on length of time in treatment was available from Wales, Scotland or Northern Ireland. For England, an analysis of national drug treatment data for 2005 to 2011 reported that heroin users were typically in contact with the treatment system for about four years, though perhaps not continuously. After typically two years in and out of treatment, around half of heroin users left treatment and did not return. Most patients still in treatment were a mix of recent entrants and those known to treatment for some time and had several treatment journeys; a third had been in and out of treatment at least three times. About one in ten heroin users had been in long-term continuous treatment. Over this period the caseload included an increasing proportion of older heroin users who had been in treatment longer than average, were more complex to treat, and less likely to complete treatment.

Using the same data source an analysis was conducted for the featured report of the 50,224 patients who started an episode of opioid substitution therapy in England in 2007/08, following them up over the five years to 2012/13. Typically they spent nine to ten months in uninterrupted treatment. About four out of ten left treatment within six months and 55% within a year, rising to 85% within five years. About half had multiple treatment episodes, reflecting the relapsing nature of addiction. For the remainder, their one uninterrupted treatment episode typically lasted just over two years. Just 15% of all the patients had remained in uninterrupted treatment over the whole five years.

These studies show that contact with opioid substitution therapy in England is typically episodic, marked by periods in treatment, drop-out or attempts at abstinence, relapse, and return to treatment. For most, treatment is episodic and relatively short. A small minority (10–15%) have been in continuous treatment for five years or more. A larger minority may not be in treatment long enough to derive long-term benefit. The ‘being parked’ analogy may not be correct: most people get out of the car and walk away.

Impact of time-limiting therapy

There is evidence that time-limiting opioid substitution therapy would have serious negative unintended consequences and very little evidence that it would be beneficial.

There is strong evidence that time-limiting therapy or enforced detoxification from heroin would lead to increased rates of relapse and that the course of heroin dependence is prolonged and relapse is common after leaving treatment – even if a service user wants to achieve abstinence. Limited but compelling evidence from the USA shows that introducing time limits is related to high rates of relapse to opioid use and other unintended consequences, including a review of 20 studies which found high rates of relapse to opioid use after methadone treatment was discontinued. Increased opiate use has been reported during mandatory tapering of prescriptions. Furthermore, a higher rate of illicit opiate-positive clients has been found in clinics oriented to time-limited treatment as opposed to long-term maintenance.

There is strong evidence that withdrawal of opioid substitution programmes would increase acquisitive crime. In California withdrawal was associated with more crime, drug dealing, and heroin users’ contacts with the criminal justice system. Two recent UK analyses found that the rise in heroin use accounted for 40% of the rise in acquisitive crime in England and Wales from 1981 to its peak [in the mid-1990s]. Similarly, providing opioid substitution programmes is thought to be associated with 25–33% of the fall in some types of acquisitive crime. Time-limiting the treatment is therefore likely to significantly increase acquisitive crime.

There is strong evidence that time-limiting opioid substitution therapy would increase the spread of blood-borne viruses. Stopping the therapy can lead to an increased risk of viral transmission and overdose, and treatment orientated to rapid abstinence produces worse outcomes than treatment initially oriented to maintenance. Increasing provision of the therapy reduces the spread of blood-borne viruses. Retention in opioid substitution therapy reduces injection frequency and, combined with the availability of needle and syringe programmes, reduces the risk of blood-borne viruses, in particular transmission of hepatitis C among injectors. Opioid substitution therapy also reduces the risk of transmission in prisons. There is strong evidence that opioid substitution therapy can prevent the spread of HIV infection.

There is strong evidence that time-limiting opioid substitution therapy would increase the rate of overdose deaths. While in treatment, a patient’s risk of heroin overdose death is greatly reduced (1 2), but then doubles following detoxification from the treatment. In the USA, ending programmes greatly increased death rates among heroin users following discharge. Expanding the treatment can reduce the overall rate of overdose deaths in the community. In prison the treatment is thought to reduce self-inflicted death at the start of imprisonment, and provided prior to release can reduce (1 2) the high risk of fatal overdose during the first month of liberty and subsequently.

There is evidence that a blanket policy of time-limiting opioid substitution therapy would lead to medico-legal challenges and may not be implementable. The treatment is recommended by the UK’s National Institute for Health and Clinical Excellence (NICE) and in UK clinical guidelines. Prescribers (usually but not exclusively doctors) have clear guidance from the General Medical Council (GMC) to “provide effective treatments based on the best available evidence ... If patients are at risk because of inadequate premises, equipment or other resources, policies or systems, you should put the matter right if that is possible. You must raise your concern in line with our guidance and your workplace policy.” Time-limiting opioid substitution therapy would put a doctor in a position where they are ignoring guidance from their professional regulator. It is our expert opinion that many would be reluctant to implement such a policy against their professional judgment, based on individual clinical assessment. They might find alternatives such as very slow detoxification regimens. This could result in ineffective low-dose treatments and potentially create an ‘underground’ prescribing system and make it difficult to exercise quality control.

There also may be medico-legal challenges if opioid substitution therapy was time-limited or contracted to be provided outside NICE guidelines. In 2006 there was a legal challenge from 200 ex-prisoners who claimed they had been given inadequate treatment for opiate withdrawal in prison. The Home Office settled out of court and had to pay damages. There might also be legal challenges on the grounds of discrimination if opioid substitution therapy was restricted. In the USA, the Legal Action Centre (2011) concluded that denying access to the treatment in the criminal justice system, as part of a blanket prohibition or without individualised evaluation, violated the Americans with Disabilities Act and the Rehabilitation Act. They argued that attempts to justify denied access on the grounds that it is “substituting one addiction for another” or is not a valid form of treatment should not defeat a claim under the Acts, as such views run counter to objective evidence concerning treatment for opiate addiction. Furthermore they advised that denial of access pursuant to a larger policy prohibiting the use of any prescribed controlled substance is also likely to violate the Acts, due to their disparate impact on opiate-addicted individuals receiving or in need of opioid substitution therapy.

The authors’ conclusions

The overall conclusion of this report is that the evidence does not support the case for imposing a blanket time limit on opioid substitution therapy for heroin users, and this approach is not advised by the Advisory Council on the Misuse of Drugs. Evidence strongly suggests that time-limiting the treatment may have significant unintended consequences, including increasing drug-driven crime (and national crime statistics), heroin overdose death rates, and the spread of blood-borne viruses including hepatitis and HIV. Those implementing this approach could also face medico-legal challenges.

Rates of relapse are high when heroin users voluntarily detoxify and complete the treatment, illustrating the difficult, relapsing nature of heroin addiction and the challenge we face in enabling heroin users to achieve a range of recovery outcomes – particularly with our ageing heroin population with limited recovery capital. The current trends of use of opioid substitution therapy indicate that most heroin users are not ‘parked’ for long periods of time. Use of the treatment appears to be similar to use of heroin for the majority: that is, episodic and characterised by periods of treatment, attempts at abstinence, relapse and return to treatment.

We are concerned that more individuals appear to be in opioid substitution therapy for too short a time to benefit than are in it for more than five years. For those who need the treatment, access should not be limited, but rather enhanced. It is therefore crucial that we explore why people drop out of opioid substitution therapy, particularly when discharge is unplanned.

The Advisory Council notes there is strong evidence that opioid substitution therapy can be a very helpful part of treatment and recovery for those with heroin dependence, but thinks that is unhelpful to focus on the medication alone. It recommends continued support for high quality opioid substitution therapy with comprehensive psychosocial and recovery interventions, which evidence shows is more likely to support individuals ultimately to achieve abstinence and other recovery outcomes. We note that ‘medication alone’ without concomitant psychosocial interventions and recovery support is not in line with national guidelines, and limited recovery outcomes are likely.

Findings logo commentary This report comes on the heels of the 2012 report of an expert group convened for the UK Department of Health on how methadone and other medications can more fully aid recovery. That group revisited some of the issues the following year in response to a request channelled through the Chief Medical Officer about how often treatment should be reviewed to check whether alternatives should be tried, suggesting that government concern over patients ‘getting parked’ in maintenance programmes had not been assuaged by the initial report. These two incidents may have been among the four referred to by Paul Hayes, the former head of England’s National Treatment Agency for Substance Misuse. In 2013 he commented, “There’s still an appetite in bits of government to re-ask the question about time-limited methadone ... which in my time they asked four times and always got the same answer. They keep hoping they’ll finally find someone to tell them what they want to hear, but the evidence remains the evidence.”

June 2014 was the date of the further request to the Advisory Council which resulted in the featured report, so similar government requests must now total at least five. Such persistence seems a sign of the deep-seated hostility to widespread, indefinite maintenance prescribing within parts of the UK government, expressed in 2012 in the Putting Full Recovery First report from the same ministerial drug policy committee behind the latest request. They aspired to bring an “urgent end to the current drift of far too many people into indefinite maintenance, which is a replacement of one dependency with another”. A similar stance had been even more trenchantly expressed in Conservative Party policy in the run up to the May 2010 election, characterising methadone maintenance as “drug dependency courtesy of the state”.

This latest government request to consider the issue was the one which in public most explicitly sought grounds for setting time limits to opioid substitute prescribing. The resulting rejection of limits was also the most explicit to surface from an official body. In direct and unambiguous language, not only did the featured report foresee negative health and crime consequences from time limits or otherwise curtailing prescribing, it turned the tables by arguing that far from being in treatment too long, generally patients in England were there too short a time, and that rather than restricting access to maintenance, access should be increased. In this they echoed the comments of US recovery ‘guru’ William White for a Scottish report which, as in England, responded to government concerns over the role of methadone in recovery: “In the US, there are periodic moral panics about the idea of patients being on methadone for prolonged periods – an image that obscures the real problem which is that most patients are not on methadone long enough, eg, high rates of early drop-out, administrative discharge and rapid resumption of opioid addiction.” The Advisory Council also extended the argument to medical ethics and practical feasibility, resulting in a report which can be seen as comprehensively repelling the anti-maintenance lobby within government discerned by Paul Hayes.

However, in the person of Work and Pensions Secretary Iain Duncan Smith, that lobby remains unconvinced. A few days after the featured report was released he responded in the Sunday Telegraph newspaper. As the newspaper group’s web report put it, he urged his colleagues “to fight ‘vested interests’ in pharmaceutical companies and treatment centres who profit from ‘merely replacing one addiction with another’ by keeping addicts hooked on legal heroin replacements.” Despite the evidence gathered for the report, he stuck by his “parked on methadone” analogy, and accused his own government’s official advisers as “providing cover for perpetuating drug addiction in the UK” – an accusation the gravity of which can hardly be exaggerated.

Professor Neil McKeganey represents the academic arm of the lobby concerned that too much methadone is prescribed for too long. His response to the featured report charged it with a “regrettable reluctance to subject the [UK methadone] programme to much needed critical scrutiny,” citing the possible inapplicability of US research, methadone-related deaths, and research from Scotland suggesting “those drug users who were prescribed [methadone] stood less chance of recovering than those who were not”. In that study a small minority of heroin users attending a primary care service were not prescribed substitute drugs. Assuming long-term cessation of injecting equates to recovery, they did indeed get to this point much more quickly than the prescribed patients. However, the study was unable to disentangle whether the relative brevity of their injecting careers was due to their not being prescribed substitute drugs, or whether they were not prescribed because they and/or their doctors thought they would soon stop injecting. Even if that was the case, in the teeth of an HIV epidemic, not prescribing seemed extraordinarily risky: a quarter died within 25 years of their first injection compared to just 6% in maintenance treatment for over five years.

Professor McKeganey’s main point was that regular and thorough assessments should seek to determine whether each individual patient is continuing to benefit from methadone; if they are, prescribing should continue; if not, it should he says cease. This formulation brings him close to the mainstream view, sharing with the report its central recommendation – that there should be no blanket time limits on opioid substitute prescribing. What might also have received the assent even of its critics was the report’s echo of an earlier UK expert group’s call for substitution therapy to become ‘recovery-oriented’ by allying medications with comprehensive psychosocial and recovery interventions. It was through these rather than blanket time limits that the Advisory Council saw patients being able to achieve “abstinence and other recovery outcomes”. However, “the reality of scarce health resources and economic austerity” which Professor McKeganey saw as demanding limits on methadone prescribing might even more decisively limit the extent to which it can be supplemented by expert and expensive therapies. Criticising methadone programmes for failing to ensure patients receive psychosocial counselling, Iain Duncan Smith saw this as an argument for restricting those programmes, not funding them more generously.

Drug and Alcohol Findings has traced the recent history of opposition to maintenance in Britain in a hot topic entry, which dated the current debate back to the mid-2000s and the preceding Labour government’s concern to contain cost and free up treatment slots by getting patients to the point where they could leave treatment, partially reversing the previous emphasis on retention.

Thanks for their comments on this entry in draft to Annette Dale-Perera, co-chair of the committee of the Advisory Council on the Misuse of Drugs responsible for the featured report, and to Neil McKeganey of the Centre for Drug Misuse Research in Glasgow in Scotland. Commentators bear no responsibility for the text including the interpretations and any remaining errors. At the time the featured report was being drafted, the author of this analysis for the Effectiveness Bank was also a member of the committee, though not a member of the Council itself and not involved in drafting the report.

Last revised 20 November 2014. First uploaded 12 November 2014

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Top 10 most closely related documents on this site. For more try a subject or free text search

DOCUMENT 2013 Community loses from failure to offer maintenance prescribing in prisons

DOCUMENT 2012 Medications in recovery: re-orientating drug dependence treatment

REVIEW 2012 The effectiveness of opioid maintenance treatment in prison settings: a systematic review

DOCUMENT 2014 Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations

DOCUMENT 2013 Delivering recovery. Independent expert review of opioid replacement therapies in Scotland

MATRIX CELL 2014 Drug Matrix cell A2: Interventions; Generic and cross-cutting issues

HOT TOPIC 2015 Prescribing opiate-type drugs to opiate addicts: good sense or nonsense?

STUDY 2010 The SUMMIT Trial: a field comparison of buprenorphine versus methadone maintenance treatment

DOCUMENT 2010 The Patel report: Reducing drug-related crime and rehabilitating offenders

STUDY 2009 The Drug Treatment Outcomes Research Study (DTORS): final outcomes report

Increased somatic morbidity in the first year after leaving opioid maintenance treatment: results from a Norwegian cohort study.

Skeie I., Brekke M., Clausen T. et al.
European Addiction Research: 2013, 19, p. 194–201.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Skeie at ivar.skeie@gmail.com.

From Norway, strong evidence that being in a methadone or buprenorphine maintenance programme protects heroin-dependent patients from drug-related ill-health including life-threatening overdoses and infections, even if the treatment has not completely subdued illegal drug use.

Summary An earlier report on a cohort of opiate-dependent patients being prescribed substitute opiate-type drugs (two thirds methadone, a third buprenorphine) in Norway found that even when some drug use continues, being in maintenance treatment dramatically cut drug-related physical complaints requiring hospital treatment.

The featured study of the same cohort concentrated on the minority whose treatment was interrupted or ended, generally while they were continuing to use drugs. It found physical complaints for this group too fell on entering treatment, but rebounded once patients were forced to or chose to leave treatment – seeming to confirm that the original findings were not just due to the type of patients who left, but reflected the protective influence of being in an opiate substitute prescribing programme. The following account draws on both reports.

Patients and methodologies

The cohort consisted of patients who started maintenance treatment between 1998 and June 2007 in two counties in Norway. During that period the (flexible) entry criteria for Norwegian programmes were that patients should be at least 25, heroin-dependent for several years, and have previously received [Editor’s note: clearly with no lasting success] treatment not based on substitute prescribing. Gathering data on their 200 participants in 2008/9, researchers looked back at their treatment careers and incidents of ill health based on interviews with three quarters, treatment clinic records for 9 in 10 (including urine test and assessment indications of continuing substance use), and for all 200, records of hospital care for physical complaints.

Records were obtained for the five years before each patient had first started opioid maintenance treatment. Against this baseline could be compared their health during up to the first five years while in treatment (either one episode or cumulating broken periods of treatment) and/or up to the first five years after having left treatment, either for good or as break between episodes of treatment.

What the researchers were looking for was how the number and type of physical complaints changed after entering and leaving treatment, an indication of whether it protected the patients from these forms of ill health. Specifically, they analysed records of any acute or sub-acute health problem (‘somatic’ condition) which led to an episode of inpatient or outpatient hospital treatment. Though they might have been a cause of such incidents, psychiatric problems and chronic disorders were not in themselves counted. Episodes were categorised as related to the patient’s drug use (overdoses, injecting-related, and other), non-drug-related, or injuries.

At the start of treatment patients averaged 37 years of age. For those on methadone, doses averaged 122mg a day; for buprenorphine patients, nearly 18mg. Of the 200, 149 had been in maintenance treatment continuously since they first entered treatment, at least up to the end of the study period. Among the 51 who had left or interrupted their treatment, 85% were assessed as unstable and still taking drugs when they first left.

Main findings, all patients

Standardised to per 100 patients per year, the number of episodes of hospital care for physical complaints fell from about 61 before first entering treatment to 38 during treatment, but then rose to 113 after/in between treatments. There was a similar pattern for the numbers of days admitted to hospital and the numbers of outpatient contacts.

These patterns were largely due to complaints related to drug use. The number of care episodes for these fell steeply from 32 to just under 8 from before starting to during treatment, but then after/in between treatments rose even more steeply to about 76. The pattern was the same for each of the different types of complaints related to drug use such as bacterial infections, overdoses, acute hepatitis B and C infections, and the management of withdrawal effects.

Even patients in the top quarter for continuing to use drugs while in treatment benefited significantly and substantially (a near four-fold reduction in drug-related hospital episodes) from being in treatment, though less so than patients who more completely curbed their non-prescribed drug use.

For physical complaints judged not to be related to drug use, the pattern was quite different. Compared to before first starting treatment, while in treatment hospital care episodes rose slightly from about 12 per 100 patient years to 17, and then rose again slightly to 22 after/between treatments. Care records for injuries were relatively stable from before to during and after/in between treatments.

Main findings, the 51 treatment leavers

The featured report on the same cohort focused on the on the 51 patients whose treatment was interrupted or ended, generally while they were continuing to use drugs. Compared to the majority who stayed continuously in treatment, before starting treatment they had differed little in their characteristics or in their hospital care records. But during treatment they overdosed more frequently and clinic records indicated more ongoing non-prescribed drug use.

Nevertheless these 51 patients did benefit from entering and being in treatment in the form of a 41% reduction in the number of physical complaints related to drug use which needed hospital care, including overdoses, which more than halved. This reduction was much less steep than among other patients, but remained statistically significant after the figures had been adjusted for each patient’s drug use during treatment, their employment records, and years dependent on opiate-type drugs. Once they left and were out of treatment, the number of such hospital care episodes steeply increased (nearly six-fold) to a level much higher even than before treatment, especially in the first month after leaving, when overdoses in particular became very frequent.

In contrast, across the entire time periods hospital care for physical complaints judged not to be related to drug use did not significantly differ from before to during and out of treatment, though there was an increase in the first year after leaving.

Just six of the 51 patients were known to have left treatment voluntarily and when they were not taking drugs. However, they too experienced an increase in drug-related hospital care episodes during the first year after leaving treatment, and this increase did not significantly differ from that experienced by patients forced out of treatment and/or using drugs at the time.

The authors’ conclusions

In these Norwegian counties, entering and then being in opioid maintenance treatment led to a substantial reduction in acute and sub-acute drug-related medical incidents, as judged by the number of times these were treated in hospital. This was the case even for patients who continued to use drugs while in treatment. Such health problems increased substantially after patients left treatment, to a higher level than before treatment.

Overdoses are the most frequent cause of death among dependent opioid users, so the 64% reduction during versus before treatment is an important finding and in line with the results of prior research. Injecting-related treatment episodes (bacterial infections were most common) were also substantially reduced (by 83%), probably due to patients ceasing to inject or doing so less often.

In contrast, hospital care episodes not related to drug use increased by a third during opioid maintenance treatment. Possibly this was due to closer contact with health services leading to the diagnosis and treatment of previously unidentified health problems. If so, this increase reflects improved access to health services to treat ill health, not more ill health itself. Scrutiny of hospital records uncovered no evidence that the increase was due to any adverse effects of opioid maintenance treatment.

Patients who seemed to be responding poorly to treatment because they were still taking drugs nevertheless experienced a substantial reduction in drug-related hospital care episodes while in treatment. So too did patients who voluntarily or involuntarily left treatment, generally because of ongoing drugtaking, opposition to programme rules and controls, or instability in taking their medication. Even this apparently high-risk population experienced a substantial reduction in drug-related hospital care episodes while in treatment compared to before starting. However, after leaving or in between treatment episodes, such incidents increased to five times the level before patients started treatment, most likely due to relapse to heroin use; interruption of maintenance treatment is a high-risk situation.

Given that these patients can with the help of treatment improve their health, this post-treatment increase in ill-health cannot be due just to their vulnerabilities or to excessive risk-taking. Leaving often coincides with a crisis in treatment; without the ameliorating influence of treatment, problems at that time may continue or deteriorate after leaving. In turn this directs our attention to how to improve the way we respond to actual or impending treatment exit, including the need to actively engage with patients when treatment crises emerge. Alternative medications may be considered. Patients should not be subject to involuntary discharge unless continued treatment is considered actually to threaten their health. As far as possible, services should seek to retain ‘problem patients’ in treatment. Re-admittance should be prompt when patients are ready for it.

Findings logo commentary Ironically, Scandinavian nations resistant to prescribing heroin-type drugs to heroin addicts have most convincingly demonstrated the value of this kind of treatment. Additional to this Norwegian study, restrictions on methadone maintenance in Sweden made it possible effectively at random to allow or deny this treatment, creating the level playing field elusive elsewhere where patients could choose methadone or not, meaning their progress might be due to pre-existing differences between them rather than the treatment.

The most important study tracked patients admitted to Sweden’s national methadone programme before a five-year ban on enrolling new patients. Their fate was compared to that of addicts eligible for the programme, but who did not get in before the ban or had been randomly denied entry. All this comparison group availed themselves of Sweden’s well developed detoxification and drug-free treatment services, yet over on average the next six years, 4 in 10 had died. Over about the same period, around 1 in 8 of the methadone patients had died, far fewer. Overwhelmingly opiate overdose was the main reason for the difference.

Another Swedish study (also described in The Swedish experience on p. 6 of linked PDF file) found that the annual death rate was 1% while patients were on methadone but 2% among untreated opiate users. During an enforced break in treatment, hospital admissions rose only to fall again when the same addicts were allowed to return, strong evidence that treatment was an active ingredient in avoiding illness and death.

Thanks for their comments on this entry in draft to research author Ivar Skeie of the University of Oslo in Norway. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 20 October 2014. First uploaded 10 October 2014

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STUDY 2010 Were the changes to Sweden’s maintenance treatment policy 2000–06 related to changes in opiate-related mortality and morbidity?

STUDY 2008 Mortality prior to, during, and after opioid maintenance treatment (OMT): a national prospective cross-registry study

REVIEW 2014 A review of buprenorphine diversion and misuse: the current evidence base and experiences from around the world

REVIEW 2012 The effectiveness of opioid maintenance treatment in prison settings: a systematic review

DOCUMENT 2013 Community loses from failure to offer maintenance prescribing in prisons

STUDY 2004 Opiate antagonist treatment risks overdose

STUDY 2015 Impact of treatment for opioid dependence on fatal drug-related poisoning: a national cohort study in England

STUDY 2010 Risk of death during and after opiate substitution treatment in primary care: prospective observational study in UK

STUDY 2010 The SUMMIT Trial: a field comparison of buprenorphine versus methadone maintenance treatment

DOCUMENT 2014 Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations

Needle exchange and the HIV epidemic in Vancouver: Lessons learned from 15 years of research.

Hyshka E., Strathdee S., Wood E. et al.
International Journal of Drug Policy: 2012, 23(4), p.261–270.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Kerr at uhri-tk@cfenet.ubc.ca. You could also try this alternative source.

Fifteen years of research into Vancouver’s needle and syringe programme leads to the conclusion that such programmes can stop the spread of HIV and do not increase harms. However, they can only be effective if their policies allow sufficient sterile equipment to be distributed to ensure injectors always have fresh supplies.

Summary This review covers 15 years of research into a single intervention in a single city, the controversial and much-discussed issue of HIV rates in Vancouver, Canada and their relation to needle and syringe exchange provision. The authors start by identifying guidance from organisations including the World Health Organization and the United Nations Office of Drug Control that endorse needle and syringe programmes for combating HIV, as well as a large number of studies not specific to Vancouver evidencing their benefits, including reducing borrowing and lending of used syringes and HIV infection rates among injectors and promoting entry to addiction treatment. At the same time, there is no credible evidence to support claims that needle and syringe programmes: increase drug use; encourage people to start injecting; increase the amount of publically discarded syringes; aggravate or crime; or generate high-risk social networks.

Despite this evidence, needle and syringe programmes are controversial and under-utilised across much of the world. Despite the evidence, negative beliefs about their effectiveness remain, as do concerns that they might cause harmful effects. The authors believe these concerns are in part due to evaluations of some of the first needle exchanges, specifically in Vancouver. Vancouver’s first needle exchange programme was implemented in 1988 as a response to rising injecting drug use. Controversy surrounding the Vancouver experience focused in particular on findings that needle exchange had failed to stop an alarming rise in HIV rates, and those who attended the exchange continued to share needles. These findings were cited by United States officials when enacting legislation that curtailed needle and syringe programmes. This review uses the relevant research to tell the story of what the authors see as what really happened in Vancouver.

Main findings

An estimated 13,500 injecting drug users live in Vancouver, of which one third live in a neighbourhood known as the Downtown Eastside illustration. The area suffers from poverty and crime, and much of the accommodation consists of small single occupancy rooms with poor facilities. Half of Vancouver’s injectors live in these rooms or in other unstable housing situations, with one in 10 homeless. There is also a substantial sex work economy, and public drug dealing and use are common.

Downtown Eastside. From: Hepatitis C and needle exchange part 2: case studies, http://findings.org.uk/docs/Ashton_M_16.pdf

In 1988 the first attempt to introduce needle and syringe programmes was cautious and focused on minimising public disorder. As a result, the service provided only one-for-one syringe exchange from its inception until 2002, the aims being to stop syringes from being discarded unsafely in public, to give staff more contact time with injectors, and to reduce the likelihood of injectors selling on new syringes. Strict limits on the number of syringes each injector could receive were also imposed – initially two per day or 14 per week. The process of exchange was conducted at a fixed site in Downtown Eastside during the day, and in the evening at an exchange van. By 1993, over a million syringes were being exchanged per year, and HIV rates were considered low and stable.

In 1994, injecting drug use and HIV rates in Vancouver soared; the percentage of injectors infected with the virus more than tripled to 7% from 2% the year before. The reviewers attribute this to a combination of factors including mentally ill people being removed from institutions, poor availability of social housing, and a large increase in cocaine availability. An early study found that people who attended the needle exchange were more likely to behave riskily, for example by sharing syringes, and were more likely to inject cocaine, which was increasingly becoming the main drug used in Downtown Eastside. Cocaine’s effects last a much shorter time than heroin; it may be injected over 20 times a day, while heroin is typically injected only two to four times a day. The result is a much greater demand for syringes.

In response, limits were raised from two to four syringes per day, then doubled again to eight. More mobile exchange vans were also added, and in 1997, more than 2.5 million syringes were exchanged. Following this increase in provision, one much-cited study found that people who attended the exchange more than once a week were more likely to be infected with HIV than other injectors, even after adjusting for differences in how often and what drug they injected. The study authors estimated that between five and 10 million syringes would need to be exchanged in order to meet demand, and that the needle exchange programme should be expanded. They also concluded that needle exchanges, though “an important cornerstone of HIV prevention”, were not enough to prevent rising HIV rates without increased investment in other health and drug treatment services.

Despite these conclusions, the results were deemed by many internationally – including the US Office of National Drug Control, several US senators and the US ‘Drug Czar’ – to show that needle and syringe programmes had been unsuccessful. After the findings were reported, more funding was released to increase access to Vancouver’s drug treatment and needle and syringe programmes, syringe limits increased to 14 per day, and the total number of syringes exchanged reached 3.5 million in the year 2000. Vancouver’s HIV outbreak nonetheless took years to stabilise.

A further study examined more closely the link between using the needle and syringe programme and becoming infected with HIV by following up 870 injectors initially free of the virus. Whilst those who attended the service frequently were more likely to become infected than those who did not, this was fully explained by the fact that frequent attendees were at higher risk in the first place, including unstable housing and injecting cocaine daily; there was no evidence that attendance in itself increased risk of infection.

The reviewers identify several factors which may have lead to the failure of Vancouver’s needle exchange to prevent rising rates of HIV. Importantly, many injectors were not able to access syringes due to the opening hours of the exchange, which shut in the evening at 8pm and did not open until 8am. Limiting hours was intended to reduce nearby drug use overnight, seen by some as prioritising the acceptability of the service to the community and to politicians over its effectiveness. Another factor mentioned was the usual insistence on one-for-one exchange of used for new syringes, meaning injectors who did not have used syringes to exchange were denied sterile syringes, although not all studies agreed this was an important factor. Police presence and the methods they employed were found to lead to increased risk of HIV infection because injectors became less willing to carry sterile syringes, which were sometimes confiscated, and more likely to rush injecting and share syringes either deliberately or accidentally.

Finally, the reviewers discuss more recent policy changes in Vancouver’s needle and syringe programme, a change in focus to emphasise distribution of sterile needles rather than exchanging used needles for new. Limits on the number of syringes that can be distributed were removed, the collecting of used syringes was separated from the distribution of new syringes, and more varied methods of distribution were added. These methods were found to have led to significant reductions in the rate of syringe sharing, as well as lower levels of new HIV infections.

The authors’ conclusions

The most important conclusion made by the reviewers is that attending the needle exchange in Vancouver did not increase injectors’ risks of contracting HIV; higher rates of HIV infection among those who attended frequently is explained fully by their being at higher risk in the first place due to pre-existing circumstances and behaviour, particularly the frequent injection of cocaine. Though the needle exchange did not result in unwanted negative effects, neither did it stem the spread of HIV infection. Whilst the reviewers cannot be certain why this was, they suggest that factors including limited opening hours, the requirement for one-for-one exchange, a lack of prevention and treatment services, and police crackdowns, combined to restrict the availability of sterile syringes, leading to higher levels of syringe-sharing.

The lessons from Vancouver are that the focus of a needle and syringe programme should be on the distribution of syringes to those who need them, rather than on reducing public disorder, and that the distribution and collection of syringes should be separate, while outreach work should also be used to contact harder to reach groups. Broader lessons are that the specifics of programmes and the local context must be attended to closely, as factors such as the opening hours, distribution policies, characteristics of local injectors, policing methods and so on may all influence effectiveness. In order to assess effectiveness, services should be evaluated and monitored to discover what may be holding back the distribution of syringes. Overall, it should be recognised that needle and syringe programmes can “drastically” cut the number of new HIV infections, but this requires effective implementation.

Findings logo commentary Findings editor Mike Ashton has commented extensively on the experience of the Vancouver needle exchange, and a Findings thematic review on hepatitis C and needle and syringe programmes also covered the subject. In both documents, the conclusions drawn were not significantly different from those of the featured review – agreeing that although the needle exchange did not increase the risk of contracting HIV, it appeared that way because it attracted higher-risk injectors. Nonetheless, it failed to curb the spread of infections. The Findings reviews echoed the featured review’s explanations for this failure, but also emphasised poor housing in Downtown Eastside and the risks generated by the environment as a whole, which led to one in five Vancouver injectors reusing needles even when they had access to sterile supplies. Also in agreement with the featured review was the conclusion that, rather than undermining the case for needle and syringe programmes, “the overriding conclusion from this evidence is that we need far more and far more support for this work”.

In the UK, official guidance from the National Institute for Health and Care Excellence stipulates that injectors should have more than enough sterile equipment than they need for every injection, while World Health Organization guidance also reinforces the importance of access to needle and syringe programmes. For more research evidence on these programmes and discussion of their impact, see the relevant Drug Matrix cell and Matrix Bite.

Thanks for their comments on this entry in draft to research author Elaine Hyshka of the University of Alberta in Canada, and to Jamie Bridge, Chair of the UK National Needle Exchange Forum. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 25 November 2014. First uploaded 29 October 2014

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Implementation issues in an innovative rural substance misuser treatment program.

Godlaski T.M., Clark J.J.
Substance Use and Misuse: 2012, 47, p. 1439–1450.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Godlaski at tmgodl1@uky.edu.

Detailed, frank and compelling account of what it takes in the real world (when implementers have to grapple with counsellors and organisations over which they have no control) to introduce a new treatment approach. Key lesson is that each organisation is different; being there, learning about that unique context, and taking it in to account, is what’s needed to give implementation a chance.

Summary The treatment approach called SBORT (structured behavioural outpatient rural therapy) builds on what has been learned in rural areas about individual and community characteristics and tailors approaches validated in urban settings for use with rural clients. It was developed and tested over a three-year period by academics and substance use counsellors in a rural Midwestern state in the USA. SBORT is a two-phase, intensive outpatient programme.

A ‘pre-treatment’ phase includes three individual sessions using motivational interviewing to assess an individual’s problems, develop a behavioural change contract, and begin case management. Motivational interviewing engages clients in treatment; case management helps meet their basic human needs so they can attend sessions and remain in treatment; behavioural contracting helps to direct and reward clients as they initiate specific changes in their behaviours. The treatment phase uses social skills training, an approach built on the assumption that lack of fundamental social skills creates discomfort, which leads to substance use to relieve discomfort. Social skills training focuses on enhancing patients’ skills using the group setting for teaching and practice. Additionally, culturally informed structured storytelling and thought-mapping help clients develop and practise skills by targeting their problem behaviours and their causes and consequences.

The SBORT project aimed to implement this approach at three sites which mainly provided outpatient treatment. Clients at these sites were almost all white, mainly men, and generally 25–35-years-old. One of the important features of this study was that it selected therapists to learn and adopt SBORT who were already working in the selected substance use treatment programmes. Unlike many treatment research protocols, this project recruited, trained, and supported therapists typical of rural substance user counsellors.

Main findings

Implementation was accomplished through off-site training events and individual and group consultation sessions. During three, two-day off-site training sessions, therapists and programme directors were introduced to the SBORT protocol, instructed in its treatment techniques, and practised the development of social skills. Methods used were didactic presentations of theoretical content, demonstration of treatment techniques, role-playing, and discussion.

Originally these training events were to be the primary means of implementation. However, it became clear that intensive on-site consultation by members of the research team would be more beneficial. Consequently, team members with experience in clinical work and/or clinical supervision each took a site and provided twice-monthly group and individual consultation to the therapists who over five months would be involved in implementing SBORT. Consultation consisted of both individual and group sessions in which therapists were coached in the use of SBORT therapeutic techniques like motivational interviewing, thought-mapping, and behavioural contracting. It also afforded the opportunity for therapists to raise difficulties in their clinical work which might hinder implementation. As therapists delivered the protocol, they were randomly observed by researchers and given feedback and suggestions about their performance.

At first the researchers focused on the protocol and saw therapists as independent from any context except that of their communities. They assumed that if the concepts underlying the protocol and the skills necessary to implement it could be explained, demonstrated, and practised, then implementation would be successful. However, the ways therapists behaved during training sessions indicated that the concepts in and of themselves were of no interest, nor did they seem inclined to invest the time and energy needed to learn the skills. Not until implementation moved to site-specific consultation did therapists begin to express their real concerns and to invest in learning the protocol. This change signalled a shift from the implementation of the protocol as a universal for rural settings, to its implementation in very specific organisational contexts.

In retrospect, it became clear that the therapists were not disengaged entities, rather they were nested within unique sites embedded in unique organisations. At one site therapists saw their parent organisation as unresponsive and talked of the special efforts required to change their treatment approach. At another they spoke of their isolation, lack of clinical supervision, and concern about the adequacy of their skills. At the third site they focused almost exclusively on the needs and fears of their clients in relation to specific aspects of the SBORT protocol and expressed little concern about organisational issues or their abilities to implement the protocol. Only when the research team tailored implementation by responding to local conditions did therapists become willing and able to invest time and energy in learning to execute the protocol.

Although the researchers initially saw therapists as autonomous actors, the therapists never reported seeing themselves this way: organisational context was critical for them. What the research team initially interpreted as lack of interest and intellectual curiosity may have been an inability to envision implementation of the protocol other than in their specific context. They wanted to know how to implement the protocol in their specific setting, with their specific clients, under their specific organisational conditions. Had the implementation strategy not moved to a site-specific approach, implementation might have totally failed.

The therapists’ feelings and behaviours were familiar from other implementation research. They were not inclined to read technical material, responded to on-site consultation rather than off-site workshops, those who were older or who had longer treatment or personal experience with addiction tended to have more difficulty with a novel treatment approach, they felt discounted by their own organisations, and some felt exhausted and demoralised by organisational stress. All of these factors needed to be considered to acheive successful implementation.

Measures of therapist performance indicated they followed most elements in the treatment manual in a consistent fashion, but varied on other measures. They were like individuals reading chapters from the same book with a minimum of mispronunciation, but with widely different levels of expression, comprehension, and effect. Quality of implementation is affected by a multitude of factors beyond the control of an external project seeking to implement a new treatment. Some of this variability may be the result of long exposure to organisational climates that do not foster professional growth and development, or that tend to demoralise or isolate substance use counsellors.

Substance use counselling, at least in these contexts, seems to be very sensitive to the organisational context. The question does not seem to be, ‘How do we transfer this research-based treatment approach into a rural practice environment?’ but rather, ‘How do we transfer this research-based treatment approach into this rural treatment organisation?’

The authors’ conclusions

If the importance of organisational issues encountered by this study is generally true of treatment settings, then the following are the implications:
• Those who wish to test or introduce treatment approaches must understand the organisations that serve as the context for all activities essential to the introduction of the new approach.
• This probably means that protocols must be sufficiently flexible to adapt to specific organisational conditions, without losing those elements essential to how the treatment works.
• Implementation in real-world settings demands active consultation and supervision that not only ensures training for and maintenance of adherence to the new approach, but also helps therapists tailor the protocol so that it is feasible in their settings. Feasibility appears to be critical to therapists’ adopting and implementing new treatments.
• Consultation is necessary to help therapists examine and possibly modify their beliefs, attitudes and frames of reference in order to enable them to learn and implement new treatment protocols. This is a process of assisting therapists in developing a new culture in which new treatments make sense. However, the new culture cannot be inimical to the larger organisational culture in which therapists must work.
• Those developing new substance user treatments must carefully consider the strengths and limitations of specific treatment settings, not only the characteristics and behaviours of the therapists themselves.
• Not attending to the above might mean that a new treatment approach ‘fails’ to produce desired outcomes, not because of inherent problems with the approach, but because problematic therapist–organisation interactions block implementation altogether or limit treatment intensity so much that clients do not improve.

Findings logo commentary Though presented as specific to a rural context, the discovery forced on the researchers that organisational constraints and features which promote or hinder implementation are critical is one noted consistently in research and guidance, and not one specific to rural settings. The featured report offers an unusually detailed, frank and compelling account of what it takes in the real world (ie, when researchers have to grapple with counsellors and organisations over which they have no control) to introduce an unfamiliar approach.

Thanks for their comments on this entry in draft to research author Theodore Godlaski of the University of Kentucky in the USA. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 21 October 2014. First uploaded 13 October 2014

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