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‘Everyone’s not doing it’ message offers hope for prevention

The complexity and challenge of ‘dual diagnosis’

The therapeutic potential of patients and clients

Harm reduction: what’s it for?

‘Everyone’s not doing it’ message offers hope for prevention

Science is littered with shining discoveries which became tarnished as accumulating data forced a reappraisal. In substance misuse, ‘normative education’ retains some of its shine, but what seemed the great hope for school- and college-based prevention now seems a tactic of limited application and inconsistent impact. The approach relies on the common (but perhaps at not as common as believed below) overestimation by pupils and students of how many of their peers use substances and how much they use, and/or a similar overestimation of the acceptability of substance use among their peers. Corrective survey data is expected to reduce substance use because it no longer seems ‘normal’ and ‘what everyone my age does’. For more on the thinking and research behind this strategy, see this presentation from John McAlaney of the University of Bradford.

Important recent implementations include the seven-nation EU-Dap European drug education trial and the English Blueprint trial. In the EU-Dap trial of the Unplugged programme, relative to usual lessons none of the measures of whether substances had been used in the past month were significantly reduced by Unplugged lessons which featured normative content. Regular use was reduced only in respect of smoking, and then only fleetingly. Only in respect of drunkenness were there statistically significant and lasting positive impacts, and even these were uncertain given methodological shortcomings. Blueprint’s findings were – if anything – in the ‘wrong’ direction, suggesting the lessons might have slightly encouraged substance use, perhaps partly because pupils often simply did not believe the results of the surveys of their peers they were presented with.

Moving up to university students, a British trial of a web-based intervention based on correcting normative beliefs produced unconvincing results, as had an earlier trial from the same lead author. Both trials suffered substantial drop-out which was somewhat higher among students allocated to the feedback interventions, raising concerns over whether at follow-up assessments there remained a level playing field between them and the control students not offered the intervention. The earlier trial’s finding of a greater reduction among intervention students in the average amount drunk on a single occasion was slight and not matched by overall drinking reductions, and it was unclear how missing data had been accounted for. In the later trial just a third of the students had completed the follow-up assessment which produced the most promising finding, a small extra reduction in the amount drank over the past week among students immediately offered feedback on their drinking versus those who had to wait. This one finding only reached statistical significance after using the available data to predict how much the missing students would have drunk. Other analyses found no significant effect.

So patchy have results been at US colleges that some suspect the drinks industry supports normative campaigns because they divert colleges from imposing restrictions which really would cut consumption. However, there have been notable successes (for example, 1 2) which found not just substance use reductions, but related these to normative beliefs.

Maybe it’s the context that’s wrong

One possibility is that normative approaches falter sometimes because they are embedded in programmes which unrealistically aim to prevent all substance use rather than to reduce harmful consequences (1 2), particularly applicable to alcohol in countries where its use is widespread and accepted, even among teenagers. As in Australia, in Northern Ireland an alcohol harm reduction curriculum which incorporates normative education as an important component curbed the growth in alcohol-related problems in secondary schools and also meant pupils drank less. Also in Australia, another similar curriculum with normative elements retarded age-related growth in alcohol consumption, in drinking in order to get drunk, and in alcohol-related social or health harms.

Perfect for computerised programmes

As a review for NHS Health Scotland observed, normative approaches lend themselves to computerisation and have become the mainstay of web-based interventions for people concerned about their drinking. Typically the site user completes a brief assessment of their drinking. This is then automatically compared with the corresponding sector of the general population and the results fed back to the user, accompanied by computer-generated advice tailored to the information about themselves which had been input by the user. UK-based examples include the Down Your Drink site and the Drugs Meter, which covers illicit drugs as well as alcohol.

These therapeutic applications targeting problem users are addressed by another hot topic, but the same technique can be used as a preventive tool in educational settings and for students in general. Tried in a US university which required new students to undergo alcohol education before moving into student accommodation, the results were promising. Compared to just being assessed, one of the two tested programmes led to significantly fewer adverse alcohol-related consequences, largely because it prevented escalation of drinking after starting college. In contrast, at British universities where alcohol education is not mandatory, trials (1 2) of another web-based normative intervention have produced unconvincing results. In Sweden too, when evaluated across the entire student population at two universities, on no measure did offering normative feedback after online drinking assessments appreciably or significantly improve drinking outcomes.

Why the patchy record?

Part of the reason for the inconsistency in findings seems to be that more distant (eg, “Pupils of my age in this country”) comparators are less influential than closer ones (eg, “My closest friends”). Yet youngsters who drink, smoke or use drugs probably do have friends who do much the same. There is also the risk that cliques which pride themselves on prodigious consumption will feel validated rather than mortified to hear that the ‘typical’ student is more restrained. And many college students under-estimate heavy drinking among their peers; telling them the truth could be counterproductive.

There may also simply be a disconnect between how heavily you think your peers drink and how much you drink. In Welsh universities, how heavily a student believed their friends and the average student drank was unrelated to how much the student themself drank. But a European study which included the UK and covered drug use as well as alcohol, found that student substance use was greater when they attributed relatively high levels of use to other students. The difference might have been due to the uniformly heavy drinking of the Welsh students, every one of whom had (according to UK guidelines) ‘binged’ at least once a week. They still thought their fellow students generally drank more, but were perhaps already at the maximum drinking they could manage, or saw even very heavy ‘weekend’ drinking as normal – which in this context, it was.

One freely available critique has addressed the evidence for whether young people really do generally overestimate the substance use of their peers. If they do not, the foundation for normative education crumbles and with it the rationale for the approach being effective. It judges the phenomenon probably real, but that its prevalence and magnitude and therefore its influence are all much less than some research findings imply. Among the factors casting doubt on these implications are: the tendency of young people to say they drink or use drugs less than they do, creating the false impression that they believe other youngsters use more; methodological limitations meaning the survey results against which normative beliefs are compared may themselves underestimate substance use, and young people may be right in believing their peers use more than the surveys suggest; that youngsters who tend to be seen as ‘friends’ by other youngsters may really drink and use drugs more than youngsters less commonly seen as friends; many youngsters have (unless this is demanded of them by a question set by researchers) no idea how much a typical student drinks or uses drugs, and when asked, the meaning they ascribe to ‘typical’ may not match the researcher’s intention; being asked about their own substance use primes youngsters to exaggerate the use of their peers in order not to appear out of line.

The critic’s conclusions were strongly contested, but she stuck to her guns, and made the further point that few high quality studies have supported normative approaches, perhaps because to the extent that young people do overestimate the substance use of their peers, they do so in respect of groups socially distant from them and least likely to influence their behaviour.

Normative education has not turned out to be a preventive ‘silver bullet’, but neither is it a dud – just more complicated and more limited than at first it seemed. See what you think after running this hot topic search.

Last revised 28 June 2016. First uploaded 01 May 2010

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The complexity and challenge of ‘dual diagnosis’

With as many as three quarters of their clients suffering from mental health problems, deciding how to respond is a major concern for Britain’s drug and alcohol services. The issues are many, long-standing, and generally unresolved. Should substance use services take the lead in coordinating their clients’ care, or should this be taken on by psychiatric services? Is either willing and able to take on both issues and deal with mentally ill substance users, or would a better option be to create new integrated services?

People with coexisting mental health and substance use issues often have high support needs, and poor treatment outcomes. There are various barriers to the provision of appropriate support, but equally many opportunities and occasions to improve the lives of those affected.

Dual diagnosis: more complex than the name suggests

The term ‘dual diagnosis’ is used widely, but not often consistently. The World Health Organization defines it as “the co-occurrence in the same individual of a psychoactive substance use disorder and another psychiatric disorder”, whereas the UK National Institute for Health and Care Excellence (NICE) refers to “young people and adults with severe mental illness who misuse substances”. What these two definitions have in common is a leaning towards the severe end of experiences of mental health and substance use issues. The everyday use of the term dual diagnosis is much broader, describing the presence of coexisting mental health and substance use issues, where the person may or may not have a formal diagnosis of, or meet the formal criteria for, mental illness, substance use disorder or dependence. In fact, many people categorised as having a dual diagnosis do not have a diagnosis, and many people have more than the two problems or support needs that ‘dual’ diagnosis implies. Rather than thinking of people with dual diagnosis as having two support needs, it may be more useful “to acknowledge that they have complex needs”, both directly related to and extending beyond their substance use and mental health. It is because of this that some working in the field have advocated either moving away from the term dual diagnosis altogether, or adopting the broader, more inclusive, everyday interpretation of dual diagnosis to accommodate all who would benefit from treatment that considers their coexisting mental health and substance use problems (regardless of levels of severity or diagnosis).

Mental illness and substance use: which is chicken, and which is egg?

Dual diagnosis has been on the radars of researchers and clinicians for over thirty years. In terms of the complex relationship(s) between mental health and substance use (1,2,3,4) we now understand that (among other things):
• Drinking and drug use can aggravate or exacerbate existing mental health problems or symptoms
• People may drink and take drugs to try to relieve the adverse symptoms of mental health problems (sometimes referred to as ‘self-medication’)
• Long-term, heavy drinking can cause damage to the brain which can impair cognitive functioning
• Drinking or taking drugs can induce temporary or longer-term mental health problems in some people, which may subside after the substance use has stopped
• Withdrawing from alcohol and many illicit drugs can produce or mimic symptoms of mental ill health

The chicken and egg debate may have helped to foster a climate of fragmented services

There has been somewhat of a preoccupation in the literature and in practice about understanding which comes first, the substance use issue or mental health issue – which is chicken, and which is egg? Though the answer to this question may have important implications for treatment, it would not necessarily be the most immediate or pressing concern for patients, and has arguably helped to foster a climate of fragmented services – with mental health and substance use services feeling ill-prepared or unwilling to treat patients where their own specialism isn’t seen as the primary treatment issue.

Which agency should take the lead?

The risks of people with mental health issues developing substance use problems and people with substance use problems developing mental health issues are much higher than the risks of developing mental health or substance use issues within the general population. The high prevalence of coexisting mental health and substance use problems within mental health services is well-documented, with recorded prevalence rates in various UK studies at 32%, 36%, 44%, and 46%. Rates in substance use services could be even higher, with recorded rates of 75% in drug services and 86% in alcohol services. With so many people who are affected by dual diagnosis coming through the doors of both mental health and substance use services, clinicians face a difficult challenge. How can they best serve their patients given that they only hold one piece of the jigsaw?

An influential framework for determining the appropriate approach to treatment and care is the quadrant model, illustrated ( figure) in South Staffordshire and Shropshire Healthcare’s dual diagnosis policy. It describes four presentations of dual diagnosis based on levels of severity: mild substance use and severe mental illness; severe substance use and severe mental illness; mild substance use and mild mental illness; severe substance use and mild mental illness. The provisions for treatment described in the quadrant model focus on one service taking the lead (either substance use or mental health), and then this lead service coordinating care, and seeking advice and support from the other service (either substance use or mental health). This partly resolves where ultimate responsibility lies, but leaves unanswered other questions about the nature and practicalities of the relationship between mental health and substance use services (eg, information-sharing), and also leaves unstated the roles of other support and treatment services needed by people with coexisting mental health and substance use issues.

Quadrant model of dual diagnosis

Quadrant model of dual diagnosis grouping people with a dual diagnosis into four categories or quadrants, based on the severity of their mental health and substance use diagnoses

Department of Health guidance (published in 2002) recommended that mental health services take primary responsibility for people with severe mental illness, as they would be “better placed to offer services such as assertive outreach, crisis management and long term care than the substance misuse services”. For less severe cases not eligible for psychiatric care, substance use services are seen as taking the lead. We can be reassured to a degree that patients often improve after usual substance-focused treatments, possibly because at least some emotional problems are generated by substance use and associated lifestyles. This was why NICE recommended that alcohol services faced with seriously depressed or anxious patients should treat their drinking problems first, and consider referring the patient for specialist mental health care only if psychological conditions persist after three to four weeks of abstinence.

Despite this policy direction, there are many circumstances where people are unable to access mental health or substance use services. Sometimes those with low support needs can fall short of criteria for services, and not receive anything. Where which service should take the lead is unclear or is disputed, the result can be a stalemate where neither service can or will act. The danger of these barriers being unresolved is “service users being shifted between services and falling through the net of care”.

How can we prevent people falling through the gaps?

Coordination or joint working could be the answer. But a number of practical and cultural barriers make it difficult to achieve – sectors and services are guided by different policies, there is often a disconnect between available resources and service user or professional preferences for treatment and care, and there is a shortage of designated dual diagnosis funding. A dual diagnosis handbook published by social care organisation Turning Point suggests that “commissioners might want to explore concurrent funding streams – (eg, for mental health support services and substance misuse) – or look to share budgets to provide social care for vulnerable groups”.

In a recent piece for the Guardian, Professor Liz Hughes, who has extensive clinical and academic experience in mental health, substance use and dual diagnosis, warned that “the UK dual diagnosis scene is running on nothing but goodwill by a few enthusiastic champions”. The challenge is “being able to provide effective services to people with high needs, in a time of unprecedented crisis in mental health provision and loss of mental health expertise within the substance use sector.”

One potential source of new funding comes from the Government’s Life Chances Fund. In January 2016, Prime Minister David Cameron announced that “up to £30 million” would be available for “the development of new treatment options for alcoholism and drug addiction, delivered by expert charities and social enterprises”. This funding pot is based on the model of Social Impact Bonds, designed to leverage funding to service providers, and improve the outcomes of services by making funding conditional on achieving results, rather than inputs (eg, number of counsellors) or outputs (eg, number of counselling sessions). The independent Mental Health Taskforce to the NHS recommends that applicants should “demonstrate how they will integrate assessment, care and support for people with co-morbid substance misuse and mental health problems”.

Integrated services with staff trained and skilled specifically for dual diagnosis clients represent an alternative to independent working, or joint/coordinated working. This seems like the ideal solution on paper – clinicians in these services would have shared values, policies and processes, and there would presumably be no obstacles to information-sharing. However, the evidence about the effectiveness of integrated care has so far been inconclusive. This does not necessarily preclude the development of integrated services now or in the future, but does indicate that “the case for integration [may need to be] based on practice-based evidence rather than evidence-based practice”.

Unique opportunities (and challenges) in prison settings

Dual diagnosis is a common problem in prisons. “Nine out of ten people in prison have a mental health or substance abuse problem – often together – but most do not receive the right care”. Many prisons in the UK apply a “parallel approach” to dual diagnosis, where patient care is provided by more than one treatment service at the same time. The main advantage is that the patient receives specialist help for each of the different aspects of their problem. However, given the overlap of many problems, and the historic compartmentalisation of services (whereby substance use and mental health teams have tended to refer prisoners onto each other, rather than seeking to work together), the parallel approach has been perceived as fragmented care.

Overall, the evidence suggests that prison environments present an opportunity to provide integrated care to people with mental health and substance use issues. The recommendation is that more energy should be put into improving communication, information-sharing and referrals between services, and more research should be conducted into effective psychological interventions for prisoners with a dual diagnosis.

What treatments work?

Partly due to a lack of high quality trials, there has been no compelling evidence to support the use of any one particular psychosocial treatment over ‘treatment as usual’ for people with both severe mental illness and substance use problems (1,2). A recent review of psychosocial treatments for co-occurring cannabis use (the dominant drug problem in the UK among patients new to treatment) and mental health problems found poor results across the board, equivalence among therapies, and a failure to improve on usual treatments. When the authors looked beyond the trials where participants were randomly allocated (ie, beyond the most rigorous trials), they found some evidence for the use of motivational interviewing in psychiatric settings combined with cognitive-behavioural therapy, but little for cognitive-behavioural therapy alone.

Depression plus problem substance use is the most common combination encountered by substance use services. Experts disagree about the best general approach. An Australian study suggested that in some cultures this may differ for men and women – or at least, that for men an alcohol-focus may be a more acceptable and effective way of tackling their depression and drinking, while for women a focus on depression may be preferable. Given the difficulty of identifying which problem is primary, and the risks of getting this wrong (both could have equal weight and/or be independent of each other), guidelines from the British Association for Psychopharmacology say that “pragmatically, both disorders may have to be treated concurrently”. Their freely available resource offers extensive guidance on medication-based treatments for mentally ill problem substance users.

It seems likely that many patients with depression would benefit more from addressing this directly at the same time as addressing problem substance use. One medication-based strategy was tried in a US study which selected alcohol-dependent patients whose depression was judged independent of their drinking. It found that combining sertraline for depression with naltrexone for drinking substantially and significantly promoted abstinence compared to either alone or to placebos, and also helped more with depression. This is, however, not a universal finding. Prompted by that study, researchers in New Zealand tried adding the similar antidepressant citalopram to naltrexone in the treatment of dependent drinkers suffering what for three-quarters was judged to be major depression independent of their drinking. In this case adding the medication led to no significant overall benefits in respect either of depression or drinking.

Establishing what works for patients with a dual diagnosis is not easy given the wide spectrum (and combination) of substance use and mental health problems that exist. The label of dual diagnosis itself can facilitate or impede access to treatment, and its subsequent success. Where dual diagnosis is associated with negative stereotypes it can be stigmatising for services users. Where the term is associated predominantly with severe mental health or substance use issues, it can exclude people with lower level issues who would still benefit from treatment tailored to their coexisting issues. Where the term can be powerful is in raising awareness of the gaps in support for people with complex and coexisting difficulties. Where it can also be beneficial is in promoting a language which emphasises the importance of collaboration between mental health and substance use services.

Where do we go from here?

Progress, a group of consultant nurses and expert practitioners working in the National Health Service (NHS), runs a website offering useful resources about dual diagnosis for service users, carers and professionals. This includes the stories of David, Martha, ‘God’ and Jason (based on the experiences of people with mental health and substance use issues), and information about how to find a member of Progress working near you.

NICE is in the final stages of producing guidance to improve services for people (aged 14 and over) with severe mental illness and substance use problems, not just for their immediate mental health and substance use support needs, but those relating to physical health, social care, and housing. The expected publication is November 2016, but draft guidance is available here. Recommendations include collaboration between services in mental health, substance use, primary care, and social care, as well as organisations in the community and the voluntary sector, and the agreement of a protocol for information-sharing between all relevant services. It also recommends that people with coexisting mental health and substance use issues should be encouraged to stay in contact with services, and be involved (along with their family and carers) in developing their own care plan, which should take into account how their abilities, strengths and past experiences can help support engagement and recovery.

Dual diagnosis is not a single entity but a label for differing constellations of troubling substance use and psychological problems. Present gaps in resources, knowledge and evidence about dual diagnosis are putting a strain on clinicians, and risking many patients getting lost in the system. Historically, the values and treatment approaches of substance use and mental health services haven’t always been aligned. One potentially “binding philosophical strand” going forward is the increasing importance of recovery within both services, with opportunities to define what recovery means for people under the umbrella of dual diagnosis, and create new shared values around these aims.

Read more about issues relating to dual diagnosis by running this hot topic search.

Last revised 13 July 2015. First uploaded 01 November 2010

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The therapeutic potential of patients and clients

Focus here is on gathering together examples of the many ways problem drug users and drinkers contribute to their own treatment and recovery and that of others, and among injectors in particular, help reduce substance-related harm. But first we should acknowledge the argument that even if no specific steps are taken to involve them, still treatment and harm reduction are in essence something the client or patient does rather than something done to them – that treatment, medications and needles and syringes, are not things they just receive, but things they make use of.

Patients do it for themselves

Across psychotherapy the client’s contribution to their own improvement was the theme of the book, How Clients Make Therapy Work: The Process of Active Self-healing, published by the American Psychological Association. For therapists there was a clear, overriding message: “The single most important thing ... is clients’ involvement and investment in the process. Involved clients will frequently be able to use whatever approach to therapy is being offered them. It follows that the most important thing for the therapist to do is to facilitate, support, and help develop client involvement.” The radical implication is that it is not your skills in cognitive-behavioural therapy, motivational interviewing or some other therapy which count, but how well you promote the client’s engagement in the process of getting better.

That argument was explored in our Alcohol Treatment Matrix, where we told the story of how researchers responsible for Project MATCH, the most sophisticated attempt to differentiate the impacts of distinct therapies ever seen in the alcohol treatment field, ended up prioritising not how therapies differed, but what they had in common – most of all, what the patients brought to treatment. Turning the thesis of the study on its head, they came to see treatment’s role as primarily to offer a “culturally appropriate solution to a socially defined problem” – not a ‘technical fix’ which works regardless of the patient, but a door through which they can pass to actualise their impetus to get better.

Such a perspective helps explain why in this study patients who did not return for therapy did almost as well as those who attended all 12 sessions of the longer therapies, and that how much patients wanted to change and were ready to do so beforehand was strongly and lastingly linked to how well they did.

It also helps explain why in other studies (1 2 3) patients achieved most of the improvements they would make after deciding to enter treatment, but before it had started. So-called ‘Dodo Bird’ findings that different treatments usually have more or less equivalent effects also make sense if we believe the patient rather than the treatment is the main active ingredient. An early exemplar was the surprising outcome of a seminal British study from the 1970s. It discovered that its sample of male alcoholics did as well after a single session which put the onus for improvement on them as after fully fledged treatment spanning many weeks. It seems that for some, perhaps for many, but not for all patients, by the time they have decided they have a problem and started to do something about it, most of the therapeutic work has already been done.

Resource constraints turn spotlight on mutual aid

Such thoughts are not, however, why from the late 2000s the (ex)problem substance user’s contribution started to be forefronted in the UK, but the more prosaic issue of the prospect or actuality of dwindling resources. Hard times turned thoughts to ways to make what resources were left go further by getting people out the other end of treatment rather than keeping them in, an imperative which found a more attractive expression in the recovery agenda with its emphasis on the social and occupational reintegration needed to avoid life-threatening relapse. Whether it works this way or not, mutual aid seems to offer a way to safely free up treatment slots by promoting stable recovery and providing 24/7 aftercare support to discharged patients, services unaffordable on a professional basis.

From this perspective, it is no surprise that in 2010 mutual aid groups featured in commissioning guidance from England’s National Treatment Agency for Substance Misuse, nor that the agency’s final annual plans (2009–10 2010–11 2011–12 2012–13) Resource limitations and the need to free treatment slots escalated interest in peer-based initiatives before its absorption into Public Health England saw promoting mutual aid networks as a key way to achieve its objectives. In the Public Health England era, the emphasis remained in the form of a suite of documents (1 2 3 4 5 6) encouraging and offering guidance for commissioners and treatment services on helping patients make the most of mutual aid. The message got through to commissioners and was reflected in local treatment strategies.

Resource limitations and the need to free treatment slots may have escalated support for peer-based initiatives, but these have been around for much longer and for different reasons, appealing for their empowering philosophical foundations and their promise to create a more recovery-friendly environment outside as well as inside treatment. Plans for England formulated by the National Treatment Agency for Substance Misuse saw former problem drug users becoming visible symbols of the reality of recovery, and active in making it more of a reality by becoming ‘recovery champions’, participating in local recovery networks and mutual aid organisations, and offering current problem users support to overcome their problems, reintegrate into mainstream society, and sustain recovery.

In Scotland the Scottish Drugs Recovery Consortium has declared that “Mutual-aid fellowships and other recovery self-help organisations ... are spreading across Scotland. Addiction treatment providers are steadily building more recovery pathways that connect people in treatment with local self-help and mutual-aid groups ... People in recovery are increasingly involved in ‘giving something back’ to the communities and families that have suffered from the effects of addiction.” This independent charity funded by the Scottish Government was seen by a watchdog monitoring the national drugs strategy as a sign of the Government’s commitment to its recovery-oriented agenda, though evidence that it was really making a difference was as yet insufficient, including evidence of the promotion of peer support and mutual aid.

User involvement in services

Mutual aid is not the only guise in which current or former problem substance users contribute to other people’s recovery; in various roles, they also help as peer supporters paid by services or working as volunteers. An expert group from England has explained the difference: mutual aid entails “people coming together as equals to share stories and offer support. Peer support is typically about relationships between individuals who are not ‘equal’ – inherent in the concept is the notion of a role model whose progress in recovery is inspirational and provides a platform from which to help others less advanced in their recovery journeys.” There is a difference too in the origins and ownership of these resources: “mutual aid tends to emerge from user-led structures outside formal treatment, whereas peer support may be encouraged and commissioned by those treatment agencies”.

User involvement is not limited to treatment services. For as long as there have been needle exchanges, so too have current and former drug users been at the forefront of providing a harm reduction safety net. Now they have a new role in being equipped and trained to administer naloxone to prevent opiate overdoses becoming fatal, though in some areas progress has been slow in recruiting people who may feel they have left drug use and users behind.

One of the key peer support roles for those who have been there and done it and emerged with a better life is to advocate on behalf of patients and clients still grappling with treatment systems. But this role is not universally accepted as a ‘good thing’, and in practice in both England and Scotland provision is limited and patchy, as commissioners muddle through with a variety of informal and ad hoc arrangements.

To progress practice, in 2015 the treatment services which form the Substance Misuse Skills Consortium produced a Peer Support Toolkit offering practice examples, guidance and resources to peer supporters and their managers, a sign of the importance the UK drug misuse treatment field attaches to this source of support. At a strategic level Public Health England has also contributed in the form of a guide for commissioners, providers and service users on service user involvement.

% interviewed patients attended groups or abstinent. Shows that referral by a peer active in 12-step groups worked best

Though almost universally advocated, evidence of the contribution of (ex)substance using ‘peers’ to the treatment and recovery of others is surprisingly thin because so few high-quality studies have been done, but it is not entirely absent. One of the few studies to equalise other factors by randomly allocating patients was a British trial which found that being systematically encouraged to attend 12-step groups after detoxification substantially improved attendance, especially when encouragement came from an active member of these groups rather than a doctor chart.

Indirectly relevant is a small British study of eight drug workers and 58 clients recruited at a charity working with problem drug users who were also socially excluded. The workers completed a questionnaire to elicit their personal values and this was related to an assessment of client outcomes. Workers who (like we can guess, many of their clients) prioritised stimulation and hedonism and were prepared to contravene social norms – people more open to experience and change – recorded the greatest improvements in their clients. The study’s findings were reminiscent of a US study of ex-addict methadone counsellors published in 1974, which found that rather than the ‘perfect’ profile of a stable, psychologically healthy therapist, “deviant” personalities who shared the insecurities and edginess of their patients and had a suspicious outlook on life had patients who engaged better and used drugs less. Our commentary on the British study cites other findings which seem to suggest that workers whose values and preferences deviate from the norm in the same direction as those of their drugtaking clients are most able to help them, but also cautions that this speculation is tentative; the findings are subject to alternative explanations and reliance on them is weakened by methodological concerns.

Patients as collaborators in their own treatment

As well as peer support, Public Health England’s guide describes how service users can, should, and have been involved in their own treatment and in the strategic development and commissioning of treatment services.

User involvement in their own treatment is partly driven by broader developments in health and social care aimed at engaging the client or patient as co-producer of their own care plan. Although considered appealing for their empowering, non-patronising stance, within addiction treatment such initiatives have only a small evidence base to back them. Among the studies is a British trial which found that when opiate-dependent patients chose lofexidine as their detoxification medication, they did as well as patients who chose buprenorphine, but when allocated to lofexidine by the researchers, they did considerably worse. When buprenorphine/naloxone is being prescribed on a maintenance basis, even the rather tricky start of treatment can for many patients be left for them to complete at home, rather than all doses for all patients having to be supervised and adjusted at the clinic. Another simple way to give patients control is to let them set their own dose of substitute drugs like methadone, a tactic successfully tried several times in the treatment of heroin addiction.

Choice of drinking goal – abstinence or moderation – has for decades been a controversial issue. The fascinating history is outlined in another hot topic. Findings from a major UK study and from most others support the argument that treatment programmes for dependent drinkers should not be predicated on either abstinence or controlled drinking goals, but offer both and facilitate an informed choice. In general it seems that (perhaps especially after a little time in treatment) patients gravitate towards what for them are feasible and suitable goals, without services having to risk alienating them by insisting on a currently unfavoured goal.

Involvement is, however, just that – not solo decision-making by the patient, who may have come to treatment precisely because they are looking for expert guidance. Across psychotherapy, the evidence is strongly in favour of patients and therapists collaboratively agreeing goals and how they will go about reaching them, and underscores the centrality of incorporating patient preferences when making treatment decisions.

The ferment around peer-based initiatives and mutual aid is palpable, but scientific evidence on its impact is hard to come by. Run this customised hot topic search to deliver at one click all our analyses of research on peer support, mutual aid and user involvement.

Last revised 07 July 2016. First uploaded 01 May 2010

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Harm reduction: what’s it for?

The answer to the title question seems self-evident – to reduce harm. But what counts as harm, and whose harm? Is intoxication a harm, or a benefit? If people are offended by drug use, is that a harm we need to place in the balance? What if magnifying the user’s harm from drug use deters others from turning to drugs – good or bad?

According to the UK Harm Reduction Alliance, harms may take the form of health, social or economic impacts, and may affect individuals, communities, or whole societies – a formulation which permits opposing stances in the name of harm reduction, from prioritising the health of drug users, to sacrificing this to promote other social objectives and reduce the financial burden on the state. Ambiguity of objectives within harm reduction is nested within a policy frame which may see any form of harm reduction – if acceptable at all – as a gateway to the overarching goal of stopping illegal drug use, an activity seen in and of itself as simply wrong, and/or one whose harms are so extreme that ‘no use’ is the only justifiable strategic objective. As Pope Francis put it in 2014, from this perspective, “Drugs are an evil, and with evil you can’t give way or compromise.” For the leader of the Catholic world, harm reduction in the form of prescribing substitute drugs was just such a compromise: “I would like to say with great clarity: drugs are not defeated with drugs! ... Substitutive drugs, then, are not a sufficient therapy but a veiled way of surrendering to the phenomenon.”

These opposing agendas have from the advent of harm reduction led to a shifting balance between seeing it as acceptable only in the service of the greater good of reducing or eliminating drug use, versus seeing harm reduction as the overriding objective, one which should never be sacrificed to the anti-drugs agenda. This hot topic traces such shifts in discourse and policy since the time when in the early 1980s realisation of HIV’s injecting-related spread shook up British drug policy and British drug services.

HIV roots of harm reduction

When in the 1980s harm reduction emerged in Britain as a distinct strategy, what it was for was clear: to stop the spread of HIV among injectors, and even more so from injectors via risky sex to the rest of the population. Sometimes reluctantly, its proponents accepted that prioritising this objective meant de-prioritising others, including treatment of addiction itself and the drive to achieve abstinence amongst the patients. In reaching this for many uncomfortable position, it may have helped that HIV was also spread sexually, and on this front harm reduction rather than abstinence seemed both more natural and given the lessons of UK history, more effective.

Though it did not seem it at the time, in hindsight the turning point came in 1986 in the report of a committee set up by Scotland’s chief medical officer, prompted not by a drug treatment field focused on addiction and abstinence, but by a coalition of medical and public health forces. Using the newly available test for HIV, in 1985 an Edinburgh GP had discovered that half his injecting patients were infected with the virus. The committee was drawn largely from outside the drugs field and led by Brian McClelland, director of the Edinburgh and South East Scotland blood transfusion service. For several years he had been at the forefront of moves to prevent this at first unidentified infection spreading through blood donated by infected donors, especially drug injectors and homosexual men.

Infection with HIV poses a much greater threat to ... life ... than the misuse of drugs

His committee saw preventing injecting-related spread through the eyes of infection control specialists, relegating to side issues reservations deriving from the dominant philosophies of addiction treatment, then focused on abstinence and away from the long-term maintenance prescribing of the 1970s. For McClelland’s committee, saving lives was the name of the game. Since “Infection with HIV poses a much greater threat to ... life ... than the misuse of drugs,” they straightforwardly concluded: “On balance, the prevention of spread should take priority over any perceived risk of increased drug misuse.”

What that meant in practice was that injectors who won’t stop injecting must be given clean injecting equipment and counselled against sharing it, and that maintenance prescribing was seen as a way to reduce injecting and maintain contact with injectors, not primarily as a step towards detoxification and abstinence. In a context where it was feared that confiscation of injecting equipment by Lothian’s police had aggravated the epidemic, even enforcement was to be subjugated to the new HIV agenda: “Police policies in relation to individual drug misusers should be reviewed to ensure so far as possible that they do not prejudice the infection control measures recommended.”

McClelland’s radical reversal of priorities was never fully accepted within government. The report was cited the following year when the UK Conservative government’s Norman Fowler announced the establishment of pilot needle exchange schemes to test if they could combat this deadly new infection, but in a statement which also clung to traditional aims to “reduce the extent of drug misuse” and “explain [its] dangers” to “misusers”. More trenchantly, in response to McClelland, former Scottish Health Minister John Mackay likened issuing needles to addicts to offering prospective murderers “good weapons so that you’ll murder them efficiently and quickly, and they won‘t suffer much ... heroin addiction is wrong ... we ought not as a government, as a country, be encouraging it by giving people the means.”

Also in 1987, harm reduction surfaced as a coherent philosophy promulgated to the British drugs field. In the face of HIV and an increasing drug problem, it was “High time for harm reduction”, argued Russell Newcombe in the field’s house magazine. He itemised its theoretical and pragmatic foundations, among which was that “Rather than viewing drug use simply as a ‘deviation’ to be rectified ... In many cases, even ‘dependent’ drug use can be reconstrued as just another example of the basic human desire to repeat pleasurable activities.” Across drug policy from prevention to treatment, a focus on “controlled use (rational choice, care and moderation)” would displace the focus on abstinence.

The year after this revolutionary call, in 1988 the UK government’s official drug policy advisers echoed the McClelland committee, asserting that “The spread of HIV is a greater danger to individual public health than drug misuse.” Like the Scottish committee, for the Advisory Council on the Misuse of Drugs this meant “services which aim to minimise HIV risk behaviour by all available means should take precedence in development plans.” However, abstinence remained the “ultimate goal”, if one that must be shelved when it conflicts with preventing the spread of HIV. They urged that “The different goals for drug misusers must not be seen as in competition”, but in fact they were. HIV could only be curbed by accepting drug use rather than primarily trying to stop it.

Street poster from England in 1989. ”Sharing your mate’s works means sharing with everyone he’s ever shared with.’

Street poster from England in 1989.

Hedged about as it was, at first this reversal of priorities from tackling drug misuse to tackling HIV was not fully embraced by government, which seemed keen to maintain its existing policy thrust and tack on an element of HIV prevention at the edges rather than making this the dominant theme. The Scottish government was openly dismissive of the chapter in the report calling for urgent action north of the border. However, in England by 1989 a national campaign poster was forefronting the risks of sharing needles with only the small print seeking to reduce injecting illustration. On public billboards, it symbolised the priority given to reducing the spread of HIV, a move away from the explicitly anti-drug “Heroin screws you up” campaign of a few years before, though still one seen as stigmatising drug users.

Subjugate to recovery?

It is self-evident that the best protection against blood borne viruses is full recovery

Today in the UK there remain radically different interpretations of the priority to be given to harm reduction and of its role in the response to drug problems, each self-evidently valid to their adherents. From in the 1980s it seeming obvious that harm reduction must take priority over combating drug use, now to some influential figures, the reverse seems equally obvious.

In 2012 the UK government’s ‘roadmap’ to a recovery-oriented treatment system subjugated “All our work on combating blood borne viruses” to the national strategy’s “strategic recovery objective”, arguing that “It is self-evident that the best protection against blood borne viruses is full recovery”. What ‘full recovery’ entailed was never spelt out, but what it did not entail was clear: out of the mix was remaining in methadone or other maintenance prescribing programmes, and the continuing drug use whose consequences are addressed by harm reduction services such as needle exchanges.

For the UK Harm Reduction Alliance and co-signatories including the UK Recovery Federation, the roadmap’s interpretation was not at all self-evident. Their response transformed the government’s Putting Full Recovery First title to Putting Public Health First, challenging what they characterised as an “ideologically-driven hierarchy” which places full recovery at the top, with “any other achievement marked as inferior”.

Harm reduction is the goal – not a step along the road to recovery

That theme was uncompromisingly taken up by the Australian Injecting & Illicit Drug Users League. Concerned that their nation’s harm reduction orientation was under threat from UK-style “new recovery”, they attacked the UK government’s roadmap, insisting that “Harm reduction is the goal – not a step along the ‘road to recovery’ or the path to ‘freedom from dependence’ ” – a formulation derived from their core belief that harm reduction is the “principle paradigm upon which drugs policy should be based. All other approaches (eg, demand reduction, supply reduction) can have validity only where there is strong evidence that they are appropriate, practical and equitable means of reducing drug-related harm.” Like the home-grown attacks on the same document, they reversed the primacy order so self-evident to the UK government, subjugating treatment and recovery to harm reduction, not the other way round.

Methadone maintenance – life-saver or life-limiter?

These polarities are endemic in debates about methadone maintenance and allied approaches for heroin addiction, seen as both treatments for dependence, and harm reduction while dependence continues. In 2012 a UK attempt to reconcile these objectives complained that “the protective benefits [ie, harm reduction] have too often become an end in themselves rather than providing a safe platform from which users might progress towards further recovery.” This expert group drawn largely from the drugs field was prepared to see recovery pursued even if it “will sometimes lead to people following a potentially more hazardous path, with the risk of relapse”. At the same time, “preservation of benefit” was seen as a legitimate reason for continuing treatment; not least among those benefits is the preservation of life and health. Again the attempt was made to mount horses galloping in different directions – possible at a clinical level, but at a policy level, choices have to be made.

For some prominent drugs field figures, the harm reduction benefits of remaining on methadone are a clinching argument in its favour, and a warning that an evangelistic recovery agenda will cost lives. Others think the risks worth it, arguing that “Leaving the protection of methadone maintenance treatment may increase the risk of death. But it might also be the way to a brand new life beyond your wildest dreams, where you find jobs, homes and friends.” Leaving methadone is a dangerous business, but a proportion of former patients will swim rather than sink, and for some on the banks, the sight of those ‘recovered’ swimmers leaving methadone and addiction behind seems worth the loss of others.

Different games

In these debates the fundamental question is whether harm reduction is a primary goal, a second-best outcome when recovery is for the moment unattainable, or valid only as an engagement strategy and platform for recovery. The answer flows down to operational issues, such has how to weight the alternatives when harm reduction gains are threatened by trying for ‘full recovery’, riskily entailing the end of substitute prescribing and treatment exit. Another dilemma addressed by needle exchanges since their inception in Britain is how energetically and persistently (if at all) exchange staff should pursue treatment entry and drug use reduction objectives for their clients, if this risks deterring some visitors who just want to collect equipment and go. The reverse risk is missing opportunities to make greater risk-reduction gains through treatment and cessation of injecting.

Peacemakers try to gloss over the divides with, ‘We are all in the same game in the end, aren’t we?’, posing harm reduction and abstinence-based recovery as ends of an unbroken continuum of helping the patient, to which all can sign up. But in reality these are different games, their rules and aims deriving from differences in what we value most and how we see drug use: as always bad, or only bad if it causes harm.

As so often, science will never settle these issues, but it can clarify the consequences of deciding them one way or the other. Run this search to find analyses which address harm reduction as an intervention goal.

Last revised 26 June 2016. First uploaded 27 October 2014

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