Hot topics for May/June 2016

This set starts with prevention’s great hope – school-based drug education, contending that its preventive role has been undermined by inherent contradictions. Next, what a recovery orientation means for treatment, then arguably contradictions too between the new payment-by-results commissioning mechanism and the recovery it is supposed to deliver. Finally, what makes some treatment services more (or less) effective than others, and can that be engineered by research-based interventions?

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Contents

Drug education yet to match great (preventive) expectations

What is addiction treatment for?

What about evidence-based commissioning?

What makes for an effective treatment service?


Drug education yet to match great (preventive) expectations

School-based drug education was and for many remains the great hope for preventing unhealthy or illegal substance use and the dominant form of universal prevention applied to all regardless of their risk for developing substance use problems. Across almost an entire age group, it offers a way to divert the development of these forms of substance use before they or their precursors have taken root.

Though the promise is clear, the fulfilment is less so. When results on drinking from studies up to mid-2010 were subjected to the standard assessments of a Cochrane review, of 39 which had evaluated curricula covering substance use generally, 24 were found to have had no statistically significant impacts on drinking, and in another three impacts were confined to certain subgroups of pupils. Other studies had tested alcohol-specific programmes, but the reviewers found their results less convincing.

A companion review had focused on impacts of similar programmes on use of illegal drugs. The results favoured programmes which aimed both to develop pupils’ generic self-management, personal and social skills, and to equip them to better resist pressures to use drugs by correcting misperceptions about how common use is, increasing awareness of media, peer and family influences, and teaching and practising refusal skills. These programmes “showed, on average, small but consistent protective effects in preventing drug use, even if some outcomes did not show statistical significance.”

How thin the evidence was can be appreciated by focusing on use of the drugs of greatest concern including heroin, cocaine and psychedelics, gathered together in the review under the term “hard drugs”. Of the 51 studies it analysed, it seems just two found universal school-based drug education programmes had significantly retarded use of these substances, and these were variations on the same US curriculum (1 2). In both cases it was growth in the average frequency of use which was retarded, and in both cases it was unclear whether this was due to the programme itself, or to the selection of keen or specialist educators to do the teaching while comparison lessons were delivered by the usual run of teachers. One of the studies – the largest and most recent of the two – also assessed what proportion of pupils had ever tried these substances by the one-year follow-up. Among programme schools the risk of this happening versus not happening was 20% higher – substantially in the wrong direction, but with small numbers, not statistically significant.

English and European trials disappoint

Most disappointing for Europe and for the UK were results from the English Blueprint trial and from the seven-nation European trial of the Unplugged programme.

Blueprint drug education trial in England: Recent and/or frequent drug use in year 10. By the end of the follow-up period, on none of the most relevant measures had the Blueprint programme further retarded growth in substance use.

By the end of the follow-up period, on none of the most relevant measures had the English Blueprint programme further retarded growth in substance use

The multi-million pound trial of the Blueprint programme implemented in 23 schools in England in 2004 and 2005 was the largest such study in the UK. Its programme featured advanced interactive teaching methods reinforced by parental and community-wide components, the impacts of which its government funders expected to “trigger a fundamental assessment of the place of drug education” in UK drug policy. If it did, it would be to confirm that drug education in secondary schools makes only a minor contribution to the prevention of problems related to drinking and illegal drug use, though the evidence in respect of smoking is stronger. By the end of the follow-up period, on none of the most relevant measures was there any sign that Blueprint had retarded growth in substance use any more effectively than usual lessons in the non-Blueprint schools chart. If these are the results when schools are aided by a research team offering training and support beyond that normally available, the preventive impact of such programmes in normal practice is very unlikely to be substantial, and very likely to be no greater than usual teaching.

Unplugged was the largest European drug education trial ever conducted and tested a sophisticated US-style social influence programme. Cochrane’s reviewers pronounced it among the few to have promise as a model for reducing drink-related problems. At a follow-up 15 months after the lessons ended, its best results were registered in respect of having been drunk (14% in Unplugged schools v. 18% in comparison schools) or drunk three or more times (4% v. 6%). The remaining five of the seven measures of substance use were also on average lower among Unplugged pupils, but these differences did not meet usual criteria for statistical significance. The generalisability of the results to all schools and all pupils, the feasibility of the programme, and the validity of the findings themselves, were seriously undermined by the loss of both schools and pupils to the study. This meant its findings could only be considered applicable to the roughly half of schools prepared to take on the burden of the research and interventions, and to the minority of the entire pupil population taught in such schools and who completed the researchers’ surveys. Among schools which did take on the intervention, the parental and peer-leader supplements did not prove feasible and implementation of the core curriculum itself was, the researchers said, “just moderate”. Unplugged probably did have some of the intended effects, but the results were patchy, modest and usually statistically insignificant.

Inherent contradictions

What might lie behind such disappointments can be divided into at least two possibly interrelated domains: contradictions in principle, shortfalls in practice. Among the first is the contradiction between the objectives of education and those of prevention: the former seeks to empower children to think for themselves and open up new horizons, the latter to channel thoughts, attitudes and actions in ways intended by programme developers and teachers. Then there are potential contradictions within prevention programmes themselves. Education seeks to empower children to think for themselves, prevention to channel them in pre-ordained ways Some aim to limit young people’s autonomy in their choice of friends and substances by extending autonomy in decision-making, to encourage conformity to non-drug use values by discouraging conformity to other young people, or to develop team work and social solidarity without accepting that youngsters may express this by sharing substance use with their peers.

Commenting on the generally poor preventive impact in particular of school-based prevention programmes, an internationally recognised authority reminds us that for young people, smoking, drinking and drug use are among the symbols distinguishing their identities and their sub-societies from those of adults – a “performance” in front of other young people to mark their belonging to the group and to distinguish them from ‘outsiders’, yet at the same time markers of their passage to adulthood. Stressing that they are too young for these adventures risks bolstering their attraction as markers of being ‘grown up’. School programmes founder because “Drinking, smoking, and drug use are part of worlds of youthful sociability. These worlds mostly operate away from the adult worlds of the home and the school, and in fact are often resistant to adult efforts to intervene in their operation. The fact that school-based drug education is school based is one of its difficulties: it is an attempt by the adult world to impact on the worlds and subcultures conducted by young people themselves.”

Perhaps hampered by such contradictions, the main practical shortfall is that impacts on substance use are usually at best minor and short-lived. At first the newer normative education approaches appeared to offer hope, curbing use by showing pupils that their friends and peers were less likely to have tried drugs than many believed – that not using was ‘normal’. Blueprint and the EU-Dap trial were among those which tarnished this promise, partly because youngsters who drink, smoke or use drugs probably have friends doing much the same. However, the tactic still has some research support.

In a wider context it may be unrealistic to expect any preventive impacts of school-based drug education to surface above the much more profound effects of the child’s parenting, their position and integration in society, and the nature of that society. In a US follow-up study of over 12,000 adolescents, connectedness with adults and school were consistently associated with positive health choices, including reduced levels of alcohol and drug use. It’s not that the school is unimportant, but that what is important is not specific lessons, rather the fostering of supportive, engaging and inclusive school cultures which offer opportunities to participate in school decision-making and extracurricular activities. These are associated with better outcomes across many domains, including non-normative substance use. As well as facilitating bonding with the school, such schools are likely to make it easier for pupils to seek and receive the support they need. In these ways schools seem to build up protective factors and diminish risk factors in their pupils in ways in which specific drug education teaching may be able to contribute to, but only as a minor element.

Aim at harm, not use?

Rather than education inevitably having little preventive impact, perhaps we are measuring and seeking to prevent the wrong things. One possibility is to switch the objective to harm reduction rather than preventing or delaying substance use as such (1 2), particularly for alcohol in countries where its use is accepted and widespread, even among teenagers.

Most recent UK finding comes from Northern Ireland, where the Australian ‘SHAHRP’ alcohol harm reduction curriculum has been adapted for local secondary schools. An evaluation found it curbed the growth in alcohol-related problems during the teenage years and also meant pupils drank less. Effects were most apparent when the lessons had been taught by voluntary-sector drug and alcohol educators rather than the schools’ own teachers, and among the just under half of the pupils who before the lessons started at age 13–14 had already drunk ‘unsupervised’ without adults being present.

Findings in Northern Ireland paralleled those from the original programme in Australia, where harm-reduction effects were greatest among the higher risk pupils who had already drunk without adult supervision; at each follow-up point they experienced about 20% fewer harms than control pupils. A derivative of SHAHRP has also more recently been evaluated in Australia, where compared to pupils in control schools it retarded age-related increases in the amount drank and resultant harms. As in Northern Ireland and in the previous Australian study, the lessons were most effective among children who started the trial most engaged with drinking – in this case, not defined as unsupervised drinkers, but the roughly a fifth of pupils who at the start of the trial usually drank heavily when they drank. Though this was not the case in a smaller Australian pilot study, still the pattern of results is indicative of the potential for harm reduction lessons to reduce risk where such reduction is most needed – among higher risk teenagers who may see the lessons as more relevant, and who may already have experienced the harms the lessons aim to help them avoid.

This is education

Another possibility is to treat drug education as education, divorcing it from prevention objectives. According to an international authority on alcohol prevention, “curricula might well be based on general educational principles, rather than framed by ideology. Students are citizens and potential future consumers, and with respect to these roles, it is appropriate to provide them with biological and social science information about psychoactive substance use and problems, and to encourage discussion of the intellectual, practical, and ethical issues these problems raise.” In this vision, in drug education as in other topics, schools are seen as ‘teaching about’ agencies rather than the ‘teaching to’ (or not to) implied in a preventive role.

Rejecting pre-set prevention objectives, in very similar terms one of Britain’s most experienced and influential drug educators has called for drug education to come in to line with education on other sensitive issues such as politics, religion, and abortion: “identifying objectivity, ensuring factual accuracy, inviting balance, neutral ‘chairing’ of discussions, etc ... Young people know when they are being trusted to think for themselves, and when they are not. The older they get, the more they reject education which assumes that only manipulation and control can prevent their making the wrong decisions, and which presents them with ready-made rights and wrongs, as if we had failed them so dramatically that they cannot work these out for themselves.”

Other ways to prevent

As the UK’s National Institute for Health and Care Excellence has recommended in respect of drinking, reducing related problems relies mainly on policy initiatives which tighten alcohol availability in ways which affect the entire population whether they choose it or not, rather than attempting via education or other means to change individual choices about drinking. However, this is not an either/or choice; curtailing availability may be dominant in effectiveness, but does not preclude attempts to inform and/or influence individual choices, especially if policymakers exercise their choice not to dramatically tighten availability through measures like setting a high minimum price.

If the prevention role of secondary school education is downplayed, we may instead see that role moving down the age range and being incorporated in general early-years character development, for which promising results have been found. Interest has centred on the Good Behaviour Game, a classroom management technique implemented in the first years of primary schooling. Well and consistently implemented, by age 19–21 it has been estimated that this would have cut rates of alcohol use disorders from 20% to 13% and halved drug use disorders among boys. In the Effectiveness Bank you can read our analysis of the study and of a practitioner-friendly account of their work from the researchers.

Another approach is to engage the parents, something it has generally proven difficult to do in Britain. In Sweden this difficulty was partly overcome by capitalising on the fact that schools start each term with a parent information meeting. Across the final three years of compulsory schooling, the Örebro Prevention Programme used these meetings to advise parents to maintain a zero-tolerance stance towards youth drinking and to communicate clear rules to their children, reinforced by inviting parents to sign agreements about their positions on (among other issues) youth drinking. Pupil surveys revealed a substantial retardant effect on how often pupils had been drunk, an effect no less apparent among high-risk pupils who said they had already been drunk before the programme started.

However, a later Swedish trial conducted by researchers not involved in the programme’s development failed to replicate these initial findings, a not uncommon pattern when prevention programmes emerge into more routine implementation after successful trailblazing projects often led by the programmes’ developers.

Accepting the initial results as an indication of the programme’s potential, the question remains whether it would have the same potential in drinking cultures like that of the UK. A trial in the Netherlands of a Dutch version may be a better pointer to how it would perform in Britain. If so, it suggests that it would be an effective addition to alcohol use prevention lessons, but not the standalone success it was at first in Sweden.

UK policy and practice

Despite repeated calls, the natural home for substance use education – personal, social and health education – remains outside the national curriculum, leaving no set mandate on schools (or model for schools not required to implement the curriculum) to tackle substance use, other than teaching in the first years of secondary school focused on the effects of recreational drugs.

Another deep hole in support for drug education was left when in 1993 central funding for local authority health/drug education coordinators was withdrawn, depriving local areas of advice and support, and depriving Britain of a corps of practical experts who had been developing their joint understandings of how to do drug education since 1986. The network of coordinators in 135 posts was rapidly denuded, the experts scattered, and no alternative ‘university’ of practice emerged to take the place of coordinators’ network. The fear soon seemed to be realised that without their support for drug education, it would be marginalised as schools focused on mainstream subjects. Nevertheless, many individuals from among their ranks remained influential, a sign of the professional development fostered by the initiative.

For the UK today the most important guidance on alcohol education was issued in 2007 by the National Institute for Health and Care Excellence (NICE). It said education “should aim to encourage children not to drink, delay the age at which young people start drinking and reduce the harm it can cause among those who do drink”. Recommendations included ensuring alcohol education is an integral part of science and personal, social and health education (PSHE) curricula. The committee stressed that education should be adapted to its cultural context, noting that in the UK “alcohol use is considered normal for a large proportion of the population [and] a ‘harm reduction’ approach is favoured for young people”.

Those views were reinforced in a set of standards on preventing harmful drinking issued by NICE in 2015, which stressed that “Learning and teaching about alcohol should be contextualised as part of promoting positive messages and values about keeping healthy and safe ... information-giving is not as effective in engaging children and young people in the topic and in affecting attitudes, values and behaviour.”

Inspections in 2012 of PSHE lessons suggest English schools were far from adequately implementing NICE’s recommendations. Only in just under half the inspected schools had pupils learnt how to keep themselves safe in a variety of situations, and the deficits were particularly noticeable in respect of drinking. Inspectors found that although pupils understood the dangers to health of tobacco and illegal drugs, they were far less aware of the physical and social damage associated with risky drinking. The report attributed these deficiencies in part to inadequacies in subject-specific training and support for PSHE teachers, particularly in teaching sensitive and controversial topics.

In respect of alcohol, harm reductionists among educators would have the backing of the National Institute for Health and Care Excellence. But even if for illegal drugs too, harm reduction is a more realistic goal than use prevention, adopting it would see schools swimming against the tide of national policies in the UK which have de-emphasised harm reduction as an overarching principle.

Thanks for their comments on this entry to Blaine Stothard, independent consultant in health education based in London, England, Andrew Brown, Alcohol Programme Implementation Manager at Public Health England, and David Uffindall, formerly Coordinating Tutor for Health Education at the North Yorksshire Education Authority in England. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 09 May 2016. First uploaded 01 September 2010

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What is addiction treatment for?

What should drug addiction treatment try to achieve and for whom? The answers might seem obvious, but these are contested issues deeply entangled with today’s recovery agenda. Inevitably that ‘should’ word plunges us into the worlds of values and politics not susceptible to resolution via randomised controlled trial, while overcoming addiction cannot properly be considered without also considering the nature of ‘addiction’ itself – a territory so wide and so diverse that we can only highlight a few landmarks. Apologies in advance if what you consider major landmarks are omitted – but do use the comment/query option above to tell us.

The core issue which determined our choice is the degree to which we can limit addiction, recovery and treatment to drug use, versus the degree to which all three are inextricably bound to the ‘addict’s’ wider life context. The focus is on illegal ‘drugs of dependence’, of which the archetype is heroin – not because it is denied that alcohol is a powerful drug, but because the position of drugs like heroin in British society, and in the US society responsible for much of the research and ideas, is so different.

Our aim is not to reach a resolution of such questions, but to pose them with the aid of a few key studies and the thoughts of researchers and commentators.

We all want ‘recovery’ – but what is it?

The governments of the UK agree that above all what they want out of treatment is ‘recovery’. What they mean by that is not spelt out, but the broad themes are clear: some of the most marginal, damaged and unconventional of people are to become variously abstinent from illegal drugs and/or free of dependence and (as Scotland’s strategy put it) “active and contributing member[s] of society”, an ambition which echoes those of the government in England dating back to the mid-2000s for more drug users to leave treatment, come off benefits, and get back to work – and become an economic asset rather than a drain.

Do experts and the people on the ground see it the same way? Not all, and the definition of recovery has been so contested and so crucial that special commissions have been set up to try to reach a consensus. In 2008 the non-governmental UK Drug Policy Commission brought 16 experts together to thrash it out. They couldn’t agree what being recovered was, but did agree that getting recovered is “characterised by voluntarily-sustained control over substance use which maximises health and wellbeing and participation in the rights, roles and responsibilities of society.” Their brief report expanded on each element of the definition, explaining that that by “control” they meant “comfortable and sustained freedom from compulsion to use” – the traditional treatment goal of sustainably ending addictive patterns of substance use. But that was, they said, not enough; recovery is not just about ending pathology, but about gaining “positive benefits ... a satisfying and meaningful life”.

Note what was not in their definition. Abstinence was missing, and so too was leaving treatment, a rejection of what for government dating back to 2005 was the starting point of their emphasis on social reintegration which morphed in to recovery – the need to move patients through and out of the treatment system to free up slots in what was clearly going to be a less resource-rich era. Another government ambition was to get ex-patients back to work, and that the commission’s 16 accepted, but in a softer formulation which allowed for other routes to a meaningful and productive life. This then is the agenda for the UK’s recovery era – or at least, the most worked out version we have.

Is treatment about creating ideal citizens?

The commission’s 16 included a few ‘experts by experience’ in the form of past problem drug users or drinkers, but what of the wider views of those it is hoped will ‘recover’ from such problems? When in 2014 problem drug and alcohol users in and out of treatment in England were asked about their views on recovery, none of the drug-focused criteria identified by senior treatment staff gained widespread endorsement. Instead, participants “repeatedly argued that recovery meant ‘being normal’ and ‘living life like everyone else’.” The route to ‘normality’ entailed neither being like each other nor like other people, but was an individual itinerary, and would be diverted, limited and shaped by the usual human frailties and faults. Rejected were “superhuman” requirements which seemed to demand they become more worthy and better balanced than many people who have never had a substance use problem.

Though modestly expressed as a process of moving towards, the view that overcoming addiction entails developing lives more fulfilling than many was well represented by a definition from the US agency for substance abuse and mental health. It saw recovery from these problems as “A process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.” In there were: “Making informed, healthy choices that support physical and emotional wellbeing”; “A stable and safe place to live”; “Meaningful daily activities ... and the independence, income and resources to participate in society”; and “Relationships and social networks that provide support, friendship, love, and hope”. Explaining its vision, the agency said: “Recovery encompasses an individual’s whole life, including mind, body, spirit, and community.”

That view seems a far cry from the view of drug addiction evangelically promoted by another set of US officials – that addiction is a brain disease brought on by repeated use and that physical treatments based on the “influence of genetics and environment on gene function and expression” are a key way forward, one of the orthodoxies cogently challenged by psychologist Stanton Peele, co-author of the 1970s classic Love and Addiction.

In a blog he has listed “12 concepts of recovery that have stood the test of time.” According to this vision, the key to recovery is not better medications, but having “larger purposes that rule out the allure of drugs, or alcohol, or smoking, or shopping, or random sex.” Among these, the “number one reason” is love: “the desire to be loved and to do the best thing for the one you love is the most potent force on this list.” Also there are: feeling empowered and in control of one’s life; overriding values incompatible with a life dominated by substance use; discovery of the “real ... true ... free” self beneath disruptive and addictive behaviours; engagement with communities of interest and shared values incompatible with addiction – “The world is your oyster, a banquet of such options and opportunities”; “acceptance that this world – and your part in it – is valuable and not something to be escaped”; joy as the capacity to take pleasure in the people, things, and activities available to us; competence as the ability to master relevant parts of our environment and the confidence that our actions make a difference; the rewards of a non-addicted life such as being able “to awake with a clear head, to have the respect of others (as well as self-respect), to save money for something you want, to have satisfying, positive relationships, to care for yourself”; and self-tolerance or forgiveness.

What might that mean for treatment?

Having at least loosely defined the desired ‘recovery’ outcome, and looked at some of the mechanisms which might lead there, it should then be possible to work backwards to what that means for treatment. Logic dictates that if recovery is the aim, its characteristics should determine how to assess success in treatment, and the inputs needed to achieve it. Perhaps it is not the chronic state of addicts’ brains which leads to the chronicity of addiction, but a chronically impoverished deal in life Potentially that transforms addiction treatment into an endeavour of daunting proportions – achieving a kind of redemption in lives which among the caseloads of publicly funded addiction treatment services are often so divorced from the world’s “banquet of ... opportunities”, the love and respect of others, and the “income and resources to participate in society”, that it is hard to see them getting there, even if drug use stops altogether.

Aware of this implication, some argue that inputs related to non-drug focused elements like wellbeing and social reintegration are not essential components of the treatment of addiction, but the business of other welfare, employment and health services. The UK group which defined recovery did not let treatment off so lightly. Their definition was, they said, about “the goals of treatment and rehabilitation ... that could be applied to all individuals tackling problems with substance misuse, and all services helping them.”

Take that seriously, and surely it means treatment services will need to gear up with integrated access to vocational advancement, family services, artistic and creative opportunities, and whatever else their patients need to move towards a meaningful and productive life. Pause and shift ground from illegal drugs to tobacco or alcohol: Would you say someone who has sustainably stopped smoking or drinking, but hasn’t found a job, is still on benefits, maybe even offending, and who remains at a loss for meaning in life, has failed to recover from their addiction? Imperfect they may be, but only in ways they share with many people who have never been addicted, and perhaps too in ways not entirely under their control, like employment, housing and family relationships.

But perhaps there are good reasons why these wider issues intrude for the more socially unacceptable addictions like those involving heroin and cocaine, in a way they don’t so much for smoking and drinking. By the time you have narrowed down to the minority who try these drugs, the very few who become regular users, those of the former who become clinically dependent, and then the subset of those who want to stop but can’t without treatment, then you have selected a highly atypical and usually multiply and deeply troubled population – the caseload of addiction treatment services.

In contrast, when a broader cross-section of young men is liberally sprinkled with heroin in an environment devoid of other interests and normal ties, the more deviant and drug-experienced among them may use regularly, but on return to their normal environments, all but a few will cease regular use and stay that way without needing treatment. These were the totally unexpected observations of Lee Robins and colleagues, commissioned by the US government to investigate the looming avalanche of ex-military heroin addicts created by the war in Vietnam, where heroin was widely available to and widely used by the soldiers. That avalanche never materialised, and the returnees barely troubled US treatment services. However, the few who did resort to treatment exhibited the classic pattern of multiple problems and post-treatment relapse.

Reflecting on the implications, Robins argued that “drug users who appear for treatment have special problems that will not be solved by just getting them off drugs”. For her the reason why relapse is the norm after treatment seemed obvious: “It is small wonder that our treatment results have not been more impressive, when they have focused so narrowly on only one part of the problem.”

From the 1970s then comes this strong argument for what today we might call a recovery orientation in services treating addiction to drugs like (in terms of their social as well as pharmacological properties) heroin; that for these addicts, their drug use is entangled with social dislocation and multiple problems, which unless addressed will repeatedly precipitate them back into addiction.

Rat Park; impoverished lives generate addiction

It might easily be assumed that combat stress and relieving it with the powerful narcosis of heroin explained why the US soldiers turned to the drug, but when asked, they gave more prosaic reasons. The most common were to combat boredom and depression, pass the time, and to better tolerate the rule-bound constraints of army life. Divorced from their normal productive and social lives and responsibilities, with little meaningful to do, and with nothing active they could do to change or get out of the situation, they chose to be numbed rather than frustrated.

Frames from Stuart McMillen’s Rat Park comic book

Frames from Stuart McMillen’s entertaining and informative Rat Park comic book.

In effect, they were penned in an inescapable cage where life was impoverished and devoid of its normal rewards and interests, and in which they had been deprived of their ‘agency’ to determine their own lives. They had been reduced from fully fledged actors in life to soldiers in a war which to them made little sense. And according to psychologist Bruce Alexander, for the same kind of reasons, caged experimental rats of the 1960s compulsively pressed levers to get heroin, morphine or other drugs in experiments thought to prove these substances were inherently addictive.

Not so, argued Dr Alexander, demonstrating in his iconic ‘Rat Park’ study that given a stimulating social and physical environment which allowed the rats to be what rats naturally are – productive, active and social creatures – they consumed far less of the same drug, in this case, morphine. Even physically dependent rats would avoid further morphine and suffer withdrawals in preference if housed in an enriched environment, while isolated caged rats continued to take the drug.

It was as if, Alexander thought, the rats wanted nothing to do with morphine because it interfered with the satisfying life in Rat Park. Deprived of those pursuits and satisfactions, the drug became addictively attractive. Similar findings have (but not entirely consistently) emerged from other experiments, including one from China which confirmed that rats in a socially and physically rich environment do not find morphine rewarding, while those in more limited conditions show the expected preference for places where the drug has been available.

Stepping up the evolutionary scales, monkeys too seem to experience the protective nature of satisfying social relationships. Isolated in cages, researchers have found they self-administer cocaine sometimes to addictive levels, but when transferred to group cages holding four monkeys each, those who became socially dominant administered relatively little. Apparently their social status did a good enough job at raising their brain dopamine levels, and cocaine was not needed. The subordinate monkeys carried on fixing. There seems a clear parallel with the protective nature of social ‘capital’ (the key element of ‘recovery capital’) in human beings, and conversely the vulnerability of the socially stigmatised and excluded.

If addiction is socially generated, are treatment services part of the engine or the brake?

Far apart though the sites and the subjects were, the commonality in the findings from Rat Park and Vietnam raises fundamental questions about addiction and its treatment. Should we accept repeated and widespread post-treatment relapse as a sign of the intractability of addiction (or as US guidelines have it, the persistence of drug-induced brain dysfunction), or is it a sign of the inadequacy and mistargeting of treatment? Perhaps if we intensively, extensively and energetically addressed the multiple non-drug problems of patients seen in treatment services, addiction for them would not be chronic, and they would be more like the broader population who at times get in to an unhealthy tangle with drugs or drink, but have enough resources in their lives to sustainably pull themselves out? Perhaps it is not the chronically dysfunctional state of addicts’ brains or their intractable weakness of will which leads to the chronicity of addiction, the but the chronicity and intractability of an impoverished deal in life dealt them by fate, and by societies predicated on having winners and therefore also losers?

From this perspective, treatment may be part of the solution, but conceivably too part of the problem, playing a dual role in an addiction-generating and addiction-sustaining society. Though those who later become addicts often start with few personal, social and economic resources, the little they do have will be eroded by criminalisation and social stigma, and by services which explicitly or inadvertently encourage the adoption of an addict identity. Retaining the non-drug related social ties (family, non-addicted friends, work) and associated identities which help prevent a descent into loss of control requires drug users to keep their use secret. When they have to come out into the open, these props are lost or taken away, and with them the resources needed to lever oneself out of the loss of control represented by the term ‘addiction’. At this stage, descent into what is clinically recognised as dependence is rapid and turning back becomes extremely difficult. The ladders are hauled up (or, to switch analogies, the doors are closed behind them), blocking a return to normality, a chronicity laid at the door of the addict’s supposedly chronic, relapsing condition.

Instead of being something they do among others (such as being parents and partners, students or workers), users of illegal drugs are led to see their drugtaking as central to their identity because this is how they are treated by other people and institutions (notably the criminal justice and health systems) who have power over their lives, among whom are treatment personnel. If they too come to see themselves as nothing but a ‘junkie’, the route to recovery is likely to be that much harder. Creating a new identity both in terms of one’s self-conception and one’s social network is an important task in avoiding a return to addiction (1 2).

But accepting the identity of addict and patient gains access to the micro-world of addiction treatment services, in which (at their best) the addict is accepted, made the focus of caring attention and an optimistic assessment of what they might become, moving them beyond an addict identity rather than reinforcing it. When such relations are lacking in (non-)working, family and social lives, the revelation of finding these qualities at a service and in a counsellor or doctor have been seen as the key therapeutic force. The problem, of course, is that it is a micro environment. Even when it is 24 hours a day for months as in residential services, the effects typically erode on leaving.

Yet the truth in the focus on treatment exit within recovery thinking is that this is a big step towards the goal of being reintegrated into society, and being seen as ‘normal’, escaping, in Stanton Peele’s formulation, “perpetual identification and separation as being ‘addicts’, rather than human beings”. There may be no justification for – and severe risks in – forcing or urging people out of treatment from which they might still benefit, but few people like or feel empowered by being in treatment, whatever the condition.

Recovery treatment for the few or amelioration for the many?

Such thoughts pose practical dilemmas for treatment. If treatment takes on the recovery challenge and widens its agenda, how many fewer patients will we be able to afford to treat, and will that be counterbalanced by greater success in avoiding the revolving door of treatment re-entry due to relapse? Is it simply beyond the reach of any feasible treatment service, even with partner services, to create environmental changes of the magnitude which led to rapid, widespread and lasting remission from dependence among Vietnam returnees? Must we set our sights lower, keep patients alive and ameliorate the fallout from addiction, itself the fallout from an addiction-generating society, only modestly if at all accelerating the normal processes of remission (tracked in these studies: 1 2 3). Griffith Edwards, now deceased but arguably modern Britain’s most prominent and respected addiction treatment expert, was modest in his claims for treatment: “The basic work of therapy is largely concerned with nudging and supporting movement along ... ‘natural’ pathways of recovery.” Realistic views, or a self-fulfilling lack of ambition which fails to grasp the recovery challenge?

The dilemmas were sharply put by Professor Neil McKeganey, responsible for the Scottish national drug addiction treatment study of the early 2000s. In his book on controversies in the field, he asked whether a “revolution” in treatment was required which might see dual tracks of intensive help for the (perhaps relatively few) committed to recovery and abstinence, and a holding, harm-reduction track for the remainder. Another way to square the recovery ambition with the numbers addicted and diminishing resources would, he argued, be to refuse treatment or truncate it for those not committed to abstinence-based recovery. Without some such retrenchment, he foresaw the “very real possibility that current poor practices ... will continue ... and the vision of recovery ... will remain at the level of political rhetoric”.

Though the solutions may be unpalatable, and abstinence an unnecessary hurdle to the ‘recovery track’ or being considered ‘in recovery’, there seems no denying that getting to recovery as typically defined requires more of treatment services in the face of diminishing resources. Professor McKeganey reminds us that decisions have to be made – or perhaps more realistically, not made quite so explicitly as we muddle through and make those decisions by default, locality by locality.

With the National Treatment Agency for Substance Misuse merged into Public Health England and its much wider and prevention-oriented remit, and with the demise of the English drugs field’s representative body, DrugScope, the focus for a sense of the need to work out these issues on a national scale has been eroded. Instead of trying to determine how best to get value for money – entailing an appreciation of what ‘value’ consist of – informed sources say we are descending towards a treatment system where money only counts – where the cheapest way to provide services wins out in the face of budget cuts. According to the former head of the National Treatment Agency for Substance Misuse, Public Health England “has disinvested” from the local presence which characterised his agency, “limiting not only its ability to promote and share best practice, but also the local intelligence it previously provided which enabled Home Office and Department of Health to understand what was really happening on the ground.” If lowest-common-denominator poor practice is taking hold, no one centrally may know until the consequences become apparent, perhaps as in the recent increase in drug-related deaths.

Run this search for everything we have indexed as about the intervention goal in drug addiction treatment, and this one for the natural recovery processes which set the context for treatment.

Thanks for their insights and information especially in relation to the Rat Park study to Shaun Shelly of the University of Cape Town in South Africa; see especially his lecture, Myths of Addiction. Thanks also for their comments on this entry to Shaun Shelly, Neil McKeganey, formerly of the Centre for Drug Misuse Research in Scotland, and US-based psychologist Stanton Peele. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 10 May 2016. First uploaded 01 September 2014

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What about evidence-based commissioning?

Recently dramatically re-shaped in the UK, commissioning is the process of identifying needs within the commissioning body’s target population, and of developing policy directions, service models, and the market in services, to meet those needs in the most appropriate and cost-effective way. Despite its importance, this process is relatively unevidenced. Ticking the filter term “Commissioning services” towards the bottom of the Effectiveness Bank’s subject search page limits the main search to just those documents concerned with commissioning; generally just a few are left.

One reason for the lack of studies is that usual ways of evaluating services are not feasible for evaluating local networks of services. Large numbers of communities cannot easily be assigned at the toss of a coin to one type of commissioning process versus another. The alternative of finding naturally occurring comparisons where each community is the same except for its commissioning processes founders on the fact that these grow organically from the community.

These features mean evidence is in short supply and often has to interpret ‘messy’ real-world examples subject to multiple influences rather than deliberately changing practice to see what happens. In turn that means the results may not be caused by commissioning processes, but by other differences between times and places with one type of commissioning process and those with another.

Before getting to the evidence, first this hot topic sets the scene by looking at how services are commissioned, how this has changed, the fears about the consequences, and the safeguards to stop these happening. Then we turn to the research evidence, especially that on new payment-by-results funding mechanisms. From what has been said, it will come as no surprise that there are more questions than answers – but the questions are fundamental, setting the agenda for assessing where we have got to and are going.

All change in England

The data that we do have from the UK (dipped into below) may be seen as an argument for reforming structures, and in England that has happened on a grand scale. In 2014 this new landscape was outlined by the English drugs field’s membership body in a publication intended to help treatment services make their case for investment to commissioning bodies subject much more than previously to local political priorities.

From April 2013 national expertise, specialist national services and advice and support have been provided by Public Health England, which has absorbed the National Treatment Agency for Substance Misuse. As the task facing treatment has swelled and diversified, the financial resources are shrinking Locally the treatment budget formerly administered by that agency has been allocated to local authorities to help fund their new public health responsibilities, including the prevention and treatment of alcohol and drug problems. Clinical commissioning groups consisting of GP practices take care of commissioning NHS-funded clinical services for the local population, while criminal justice treatment-support funding is now under the control of the police and crime commissioners, and prison health services (including drug and alcohol treatment) have become the responsibility of NHS England, formerly known as the NHS Commissioning Board.

Gluing it all together is the role of local health and wellbeing boards, multi-agency groups responsible for the overall strategic direction for improving health and well-being in their areas and for coordinating NHS and local government efforts, taking over the role played by multi-agency drug and alcohol action teams which had focused on substance use and had more specific expertise in that area. The boards’ initial priorities were generally public health and health inequalities, with a distinct focus on generic preventive strategies rather than more ‘downstream’ addiction problems which had already developed to the point of justifying treatment. Whatever their focus, in practice four years on from their initiation in 2012, most boards still seemed “some way off driving the big issues”. Drug and alcohol action teams also had a commissioning role, now largely subsumed into the broad public health functions of local authorities, depriving commissioning of the accumulated knowledge and joined-up thinking built in to well-functioning teams. The anticipated result is a loss of focus on and knowledge of substance use and treatment in local strategic and commissioning bodies at the same time as national leadership has been diluted by absorption in Public Health England.

In these respects, England can be seen as reaping the consequences of the lack of local political and administrative ownership of substance use service delivery, a lack encouraged by a ring-fenced, centrally allocated budget and a centralised delivery structure in a “hub and spoke” configuration, leaving local infrastructure and critique underdeveloped and multi-agency partnerships “unable to protect investment because they were largely locally disconnected”. Locally there was little defence against the disinvestment which seems to have followed ( below) withdrawal of protected central funding.

In contrast, Scotland’s commissioning structures remain based on the equivalent to what in England were drug and alcohol action teams. But there too, a recent change in funding mechanisms arising from the transfer of responsibility for drug policy from justice to health departments has raised concerns about reduced resources. Associated with this change, funding earmarked for drug and alcohol services will fall from £69.2 million to £53.8 million in 2016/17. Government expects health authorities to make up the shortfall from health budgets, which are due to increase by 6.5%, but whether they will remains unclear. As taken further in England, this represents a move away from protecting substance use budgets, and instead leaving local funding bodies to decide how much to allocate this sector from more general income sources.

Change of direction for treatment to ‘recovery’

Commissioners also face a radical change in objective from the top, which if taken on board locally would usually preclude simply continuing with established models of service provision. Adoption of ‘recovery’ as an overarching principle for addiction treatment (see this recovery hot topic) entails extending the commissioning horizon beyond treatment episodes restricted in space (as at a clinic) and time, to the world in which the patient lives and must fully return after treatment, and to their entire life course.

Precise definitions of ‘recovery’ are lacking, but the broad themes of what for UK administrations counts as recovery are clear: some of the most marginal, damaged and unconventional of people are to become (as the Scottish drug strategy put it) “active and contributing member[s] of society” and variously abstinent from illegal drugs and/or free of dependence. Yet at the same time as the task facing treatment has swelled and diversified, the financial resources to commission services and forge links with other sectors are shrinking, and those other sectors themselves face financial pressures.

Fears over ‘disinvestment’

Diminishing per-patient funding for addiction treatment and falling total funding predate the current austerity era which took root in 2010 following the banking crisis of 2008. Though it blipped upward in 2006/07, per-patient spending on drug addiction treatment in England including local contributions and central funding has as far as can be calculated been on a downward trend since 2002/03, when it was about £3861 in 2008/09 prices. By 2008/09 it had fallen to £2756, about 29% less. After peaking in 2006/07, the total spend also started to fall. The freeze in central funding which followed almost certainly led to further per-patient, inflation-adjusted funding decreases.

Though disinvestment is not new, according to major service providers, by 2015 it had reached the point where instead of trying to determine how best to get value for money – entailing a focus on ‘value’, which might demand spending more – England had descended towards commissioning systems where money only counts, and the cheapest way to provide services wins out under the pressure of budget cuts.

A well-informed and powerful central advocate could identify such developments and support or pressure improvements, but according the former head of the National Treatment Agency for Substance Misuse says Public Health England “has disinvested” from the local presence which characterised his agency, “limiting not only its ability to promote and share best practice, but also the local intelligence it previously provided which enabled Home Office and Department of Health to understand what was really happening on the ground.” If lowest-common-denominator poor practice is taking hold, no one centrally may know until the consequences become apparent, perhaps as in the recent increase in drug-related deaths. A ‘see no evil’ scenario is also apparent locally, particularly in the lack of local data on drug-related deaths, and the narrowing down to successful treatment completion as the indicator of recovery, one only loosely related either to post-treatment poisoning deaths among patients treated for opiate dependence or to lasting remission from drug dependence.

Also gone since 2015 is the central eyes and ears and voice of the drugs field in England in the form of the now dissolved sector membership charity, DrugScope. When it was available to aid intelligence-gathering, DrugScope participated in an audit requested by the Department of Health to check how devolution to local authorities had affected commissioning and funding plans for drug and alcohol services in 2014/15 and beyond. A commentary from DrugScope highlighted the plans of a substantial minority of areas to reduce funding in 2014/15 and 2015/16, and the fact that already in 2013/14 commissioners were concerned about the “significant financial pressures they were under and the potential impact this was having on all services”.

Since then the financial screw has tightened on local authorities and will tighten further on their public health allocations year on year, forcing more radical service reviews and including merger of drugs and alcohol with other service sectors. At the same time priorities seem to be shifting to alcohol and preventive initiatives rather than illegal drugs and treatment, a move towards a public health agenda closer to the traditional remits of local authorities and of their key decision-makers in this sector, directors of public health.

In 2015 the consequences of these processes became visible through a survey of treatment services across England and interviews with senior staff. It was the third such report, and “While the first found no evidence of deep and widespread disinvestment, in its second year the survey found that many respondents were experiencing or anticipating substantial funding reductions. This trend continues in 2015, with a considerable proportion of both community and residential providers reporting a reduction in funding.” The future was likely to be gloomier still as budget cuts accumulated, meaning “challenges around resourcing safe and high quality services clearly remain”.

Linked to the drive to save money and yet produce recovery outcomes is the typically three-year retendering cycle through which commissioners seek to reshape services and/or provide them more cost-effectively. In England in 2015 nearly half the substance use services which responded to a survey had been through tendering or contract re-negotiation in the previous year and half expected to do so in the year ahead. This so-called ‘churn’ is a major diversion from service provision, leading to much of a three-year cycle being spent getting up to speed or preparing for possible de-commissioning, though many services felt the result was improved service delivery.

Safeguards and incentives

Provided outside the ambit of the NHS constitution and regulations safeguarding patient choice and competition, commissioning of addiction treatment services seems effectively unregulated. The market mechanism of patients voting with their feet to go to what for them are better quality services is often not an option, increasingly less so as mega-services take over in local areas, offering to do everything for the commissioners with consequent cost-savings.

There are, however, continuing financial incentives for local authorities to maintain and increase drug treatment numbers, and the proportion of patients who The outcome is uncertain, but could be quantity at the cost of quality successfully complete treatment, defined as the number of patients who left treatment free of drug(s) of dependence and did not return within six months as a proportion of the treatment caseload. Those who score well on these measures will to this degree (other non-drug related measures also have an effect) earn a larger share of the dwindling national pot of public health money.

Public health commissioners and planners will also be held accountable via the public health outcomes framework for England. Among the indicators of their performance is successful completion of drug treatment, the number of alcohol-related admissions to hospital, and the proportion of people entering prison whose substance dependence treatment need had not been addressed in the community.

Putting these influences together, local authority politicians and commissioners could be forgiven for aiming to maintain or increase numbers in and leaving drug addiction treatment while at the same time cutting the spend per patient and doing what they can to prevent rapid treatment re-entry. The outcome is uncertain, but could be quantity at the cost of quality. However, if disinvestment takes the form of poor quality services rather than their absence, in the treatment sector this should be picked up by the Care Quality Commission, which in 2014 set out its plans to assess whether residential and non-residential services are “safe, effective, caring, responsive and well-led”.

British commissioning systems fall short of expectations

Here we turn to evidence on commissioning and on how to improve it, much of which in the UK portrayed the shortfalls of the systems which predated the restructuring and cutbacks outlined above. Evidence-based commissioning as an ideal has always been at the mercy of politics (national and local) as well as the vagaries of budgets. Very few areas ever developed a system truly planned in a holistic, evidence-based fashion.

These weaknesses emerged in investigations in to alcohol services by the Department of Health up to March 2011, which found many areas did not have a clear, shared vision for reducing alcohol-related harm, and that alcohol strategies were often out of date or being rewritten.

Three years later the charity Alcohol Concern surveyed plans and reports from commissioning authorities in 25 areas, including 15 topping the league of alcohol-related harm. Almost all the documents mentioned alcohol, though many would not it was judged have been considered comprehensive enough to meet guidelines from Public Health England. Though included among the 15 high-need areas, four made no recommendations about tackling alcohol-related hospital admissions and seven each none about identifying and advising risky drinkers or about treating dependent drinkers. Public Health England had stressed the development of recovery-orientated systems integrating peer support and mutual aid with professional services, yet these were “scarcely mentioned”, suggesting a “discontinuity between evidence and actions”.

In Scotland in 2009 an audit of local drug and alcohol service provision systems found these poorly informed by the problems to be addressed and what works in addressing them, and in respect of drugs, unclear about what ‘value for money’ consists of. Specifically in relation to the commissioning of advocacy support for drug users, intended to equalise the power relation with services and help patients negotiate their treatment, in both England and Scotland, in 2010 national rhetoric had yet to be consistently reflected in commissioning decisions on the ground.

Also in 2010, exhaustive consultations in the south west of England revealed that procedures for commissioning offender alcohol interventions were unclear, contested, and badly under-resourced. In England’s prisons, an inquiry conducted in 2009 and 2010 found that drug treatment commissioning and funding structures had led to a “fragmented system” offering limited choices in the types of treatment and broader social support available, while across 2004 to 2009 prison inspectors reported that alcohol services present a “depressing picture” of “very limited” services, which leave offenders with poor prospects on release. Scottish prisons feature a range of alcohol-related interventions, but in their assessment published in 2011, health service researchers were concerned that many prisoners who could benefit from such interventions were being missed.

Commissioning processes do make a difference

How far things have changed and will change as in response to the recovery agenda, budget cuts and reorganisations, is as yet unclear, but what is clear is that for good or ill, commissioning processes do make a difference.

England has seen the slashing of waiting times for drug addiction treatment and a steady improvement in the proportions of patients leaving treatment at least for the time being free of dependence – both associated with explicit national drives expressed through local commissioning. Similar influences had led to increases in the proportion of patient who stayed in treatment at least 12 weeks or successfully completed before then. Alcohol treatment waiting times too have shortened in England, and in Scotland waits for both alcohol and drug treatment fell in line with a national target implemented through local commissioning structures.

In the very different public service environment of the USA, waiting times have also been a target. One national US programme halved waiting times for addiction treatment and extended retention partly by fostering a self-sustaining inter-service improvement network and a performance-analysis system linked to funding. In the US state of Delaware, state authorities effectively incentivised services to improve patient recruitment and engagement, while in Washington patients given vouchers to purchase recovery services stayed in treatment longer and were more likely to gain employment. Evaluation of an early example from the state of Maine in the USA of a system which approached payment by results ( next section) offered plusses and minuses. From 1992 services were told their current funding may depend on how well they had done the previous year, including indicators of how far patients had improved while in treatment. Effectiveness as assessed by these measures did improve, but other elements of the contract seem to have led services to focus on delivering only contracted services, withdrawing the extra inputs previously provided.

Is payment-by-results the answer?

If there are new structures and objectives for commissioners, so too is there a new mechanism in the form of payment-by-results – paying organisations, not to deliver specified services, but (in its pure form, via whatever acceptable service mix they choose) to achieve set outcomes in the form of benefits for the patients or clients. Though this seems a sure-fire shortcut to value for money, the National Audit Office has warned that payment-by-results contracts are “hard to get right, which makes them risky and costly for commissioners”, and that there is a risk of a “negative impact on value for money”.

Despite the complications and concerns described below, it is important to remember that if adequately assessed, the great advantage of paying for results is that it takes the guesswork out of wondering whether mandated or incentivised quality improvements really do make a difference. It is perfectly possible to extend retention, introduce new evidence-based therapies, or, as in this US study, to incentivise their competent and complete implementation, without this in turn improving substance use outcomes.

Getting outcome measures right is critical

Choosing the right outcome measures is critical to the success of such schemes. In a reciprocal process, this requirement is in turn affecting treatment objectives and structures. The concrete, measurable and collectable outcomes required by the schemes are bound to become not just proxies for the ultimate objective (recovery), but make-or-break sub-objectives for services whose survival depends on achieving them. If in reality the measures inadequately represent the desired recovery objective, funding based on them will send treatment services chasing in the wrong directions and punish and reward them for the wrong reasons.

When it came to making outcomes concrete enough to be used to pay English drug services, recovery through employment as envisaged in national strategies was notably lacking, perhaps a recognition that implementing this transformational vision would be a stretch when the resources to elevate patients from near the bottom rungs of society to at least near the average have been stripped back. Practicalities if nothing else mean English schemes often specify in-treatment and treatment-exit measures rather than post-treatment recovery indicators, and the post-treatment indicators are confined to routinely collected criminal justice and treatment records which do not require recontacting and reassessing patients. Such measures bear a loose relationship to lasting remission from dependence. A more comprehensive and explicitly recovery-oriented set of measures were proposed in 2012 by drugs field experts and a team from the not-for-profit Social Finance organisation to underpin investment in services.

Ironically, the English pilots placed a premium not on the long-term contact presupposed by the recovery vision and associated understandings of addiction, but on discharging patients who then are not seen again for at least a year. The individualisation stressed by recovery advocates also seems at odds with the payment mechanism. Local schemes could create a space for the patient’s ambitions in their payment criteria, but this is not a required element or one included in the national outcomes schema, nor one which sits easily within a system predicated on observable outcomes the public and their representatives recognise and are willing to pay for. Instead schemes pre-set the treatment destination in detail without reference to what the individual patient wants, and in a way services cannot afford to ignore because their financial survival depends on meeting the criteria.

Success criteria seem more suited to services geared to improvement rather than prevention of deterioration. How many people do not die, keep their homes, retain custody of their children, or stay clear crime, are not assessed, and it is hard to see how they could be. Among the typically multiply problematic caseloads of publicly funded treatment services, funding criteria focused on substance use risk distorting service provision away from meeting what for the individual are their most pressing needs, perhaps forcing them to conform to the implied view that their substance use is their primary problem and primary identity. That risk is even sharper outside recovery-oriented payment-by-results schemes, where services are judged primarily on their generation of people no longer dependent on drugs or using heroin or crack.

Levelling the playing field costs

Beyond choice of outcomes are some more general issues faced by any such scheme. Even if outcomes are ideal and could be directly and accurately measured – a task which has expensively occupied teams of researchers – what led to them would remain unclear, particularly since patients commonly traverse several treatment services and modalities before sustainably overcoming dependence. Giving all the credit to the last episode ignores the contribution of predecessors which paved the way for ‘its’ successes.

Another potential drawback was exemplified in the Delaware study cited above, where the pattern and pace of improvements suggested services did respond to financial incentives, focusing effort where rewards were greatest, but also that they did just enough to harvest those rewards without trying to do more to help their patients. It seems to reinforce concerns that (like contingency management incentives for the patients) such systems engender a mentality of doing just enough to get the money; the rewards can become the objective, not the patient’s progress.

Treatment entry processes too must change – and not necessarily for the better – due to the requirements that the new payment mechanism has convincingly unbiased ways of taking in to account the ‘degree of difficulty’ posed by a service’s case-mix and of measuring and recording the results. When funding, jobs and organisational survival ride on these assessments, leaving them entirely to the people and organisations at threat may stretch their integrity too far. In UK schemes, the most visible result has been central assessment units (or LASARS), which have a key role in setting tariffs based on patient severity and verifying outcomes. These, say the Gaming Commission, should be independent both of treatment services and their commissioners, inserting another step in the journey to accessing treatment. A keen observer of the process has raised concerns about the diversion of resources to administration and to this extra step, which means a patient’s “first contact is not with a helping service but a payment system”. The plus side may be more efficient assessment, better treatment placement, and the potential for long-term case management to start at the assessment stage.

Early results of payment-by-results in England

Evidentially, payment-by-results in health and social care of any kind is a leap in the dark. A review of reviews could find no evaluations which reported on patient outcomes, and a review specific to drug and alcohol treatment could find “little evidence that [pay-for-performance] is effective in improving client outcomes”. When Russell Webster, a leading UK commentator on such schemes, reviewed the literature, he found “consensus” about the evidence base – consensus that is “not able to give a clear indication as to whether payment by results works”, and that “unexpected, often perverse, consequences are commonplace”.

Evidential uncertainty and the risk of counterproductive effects are presumably among the reasons why the English schemes were evaluated pilots. Analysed by the Department of Health, initial results to February 2013 for the 6582 patients being treated for drug rather than alcohol problems showed consistent gains only in the proportion who while in treatment said (via forms completed by staff) they had stopped using their problem substance(s). Against the same comparators, the proportion exiting treatment free of dependence – a measure closer to the government’s recovery ambitions – was worse in the pilots. Other measures were seemingly unaffected. For the 3081 patients whose problems were mainly with alcohol, things seemed worse: no indication that the pilots had elevated abstinence rates and the proportion exiting treatment free of dependence was lower than in the rest of England and lower than in the same areas before the pilots. “Mixed” was the document’s characterisation of the results; “disappointing” might also have been justified – but these were early days.

The government analysis was followed in 2015 by that of researchers, including some involved in creating and maintaining the key data source, the National Drug Treatment Monitoring System. Their peer-reviewed journal article was based mainly on patients with heroin and crack cocaine problems treated in payment-by-results areas in the first year of the schemes compared to earlier years and other areas. The analysis confirmed the Department of Health’s key finding – that the proportion of patients successfully exiting treatment (defined in this case as no longer using heroin or crack and no longer dependent) was lower in scheme areas. The difference was slight but statistically significant and consistent across various comparisons. Also slight but significant was the higher rate of patients declining to start or engage with treatment after contact with the treatment system. Both results can be considered contrary to the government’s recovery agenda.

For the researchers the probable reasons were that services were keeping patients longer in treatment than they did without payment-by-results incentives in order to cut down on the number who return to treatment after leaving, Services kept patients longer to reduce financial losses due to returns to treatment an event which loses the service money. Though the opposite seems to have been the intention in government, this effect might well be positive. Why more would-be patients turned treatment down is even less clear. The researchers’ speculation that “linking payment to recovery-based outcomes ... is likely to have changed the nature of treatment” seems to hint at the disturbing possibility that being a unit of currency for the service sours the treatment relationship, the outcome Russell Webster foresaw when he noted that pre-treatment assessment about determining the price on the patient’s head meant their “first contact is not with a helping service but a payment system”.

More questions than answers

It will be clear to the reader that the questions about the English schemes are multiple and far-reaching, but answers are in short supply. Our Matrix Bites commentaries on seminal and key studies have posed these questions: Surely a charity or health service should not need external incentives to strive to do the best for its patients? Yet without these, would services stay unstretched within acceptable-quality comfort zones? Are pre-set objectives desirable, pushing services to deliver on national and local priorities, improving comparability across services, and preventing them glossing over their shortcomings? Or do they stifle patient-centred practice, preventing treatment objectives being based on the patient’s priorities? Maybe all the above? Does the no-return-for-a-year criterion incentivise services to make sure their patients’ recovery lasts, or tempt them to counterproductively place hurdles in the way of treatment re-entry? Where does it leave long-term continuing care of the kind advocated by some authorities on recovery? These issues are raised against the backdrop of an existing treatment system which has itself been widely criticised for failing to deliver recovery outcomes. Is that criticism justified; could the pilot mechanisms do any worse?

How to find out more

Run these hot topic searches to see what internationally or in studies confined to Britain has been discovered by evaluators about how commissioning in general and payment-by-results in particular work, and how they might work better. See also this UK-based resource pack on payment-by-results offering access to research, comment, and an interactive program to help commissioners and providers decide whether payment-by-results might be effective for commissioning a particular service.

Thanks for their comments on this entry to Russell Webster, UK-based author of a blog on payment-by-results, Sara McGrail, independent commentator on British drug policy, and David MacKintosh, formerly of the London Drug Policy Forum and now of the Community Safety Team at the Corporation of London. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 18 May 2016. First uploaded 01 November 2011

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What makes for an effective treatment service?

Under the spotlight in this hot topic is an issue which bothers everyone from patients and their families to services and the commissioners of those services – why we see major differences between the outcomes of treatment services, and what can be done to make a treatment organisation more effective. The answers range from monitoring and further training to tighter contracting of services, and the promising ‘walk-through’ tactic of experiencing your own service from the client’s point of view. These may help, but in the end we conclude there is no substitute for commitment to the patients and clients you are there to help. Without this improvement systems may not even be tried and if they are, the service may do the least possible to meet the requirements of those exerting pressure on it rather than the needs of its patients.

Characteristics of an effective treatment service

Whole organisations are not easily manipulated by researchers to see if outcomes improve, so a major source of clues to improvement mechanisms comes from simply documenting relationships between characteristics of organisations and how well they do. This kind of data comes with the important rider that a characteristic can be linked to outcomes for reasons other than cause and effect. If this is the case, then engineering more of that characteristic will not necessarily improve things for clients and patients.

From the UK we have two studies have shown us that clients may engage best with treatment when services foster communication, participation and trust among staff, have a clear mission, but are open to new ideas and practices, and that non-conformist drug workers who value hedonism and stimulation may help socially excluded clients improve most because their values match those of their clients.

Streamlined procedures can get people in to treatment quickly, and make a difference to how many can benefit from the treatment. UK studies have found that rapid entry to methadone treatment enables more people to engage with treatment (as the longer someone waits, the less likely they are to start treatment), and reduces the amount of time they are at risk from illegal heroin use.

A comparative study of three private methadone clinics in Sydney in the 1990s highlighted the importance of good organisation for improving treatment effectiveness, as well as an ethos of individualised treatment. Methadone dose too seemed important for suppressing illegal heroin use, but dose was itself related to the service’s orientation to its treatment programme. Highest doses were prescribed by a service which acted as a ‘methadone dispensary’, while patients preferred the individualised treatment orientation of a service which on average prescribed moderate doses.

However, what service providers can offer is often subject to funders’ requirements. In one US study, being constrained by funders in terms of services and ability to individualise treatments was the clearest negative factor, and quality accreditation the clearest positive in what made for a good service, with good treatment outcomes for patients.

Engagement with specialist substance use treatment is also an opportunity for often marginalised patients to access primary care and mental health services. This opportunity can be facilitated or constrained by the organisational climate. The results of a 1995 US survey of unit directors and clinical supervisors in 618 outpatient drug treatment programmes found that when staff are overburdened, and quality standards are de-emphasised, access to primary care and mental health services can be compromised.

Within non-specialist services, it is critical that staff feel treating patients with substance use issues is legitimately their business. This message emerged from the classic British studies conducted by Alan Cartwright and colleagues of the Mount Zeehan alcohol treatment unit in Kent. From the early 1970s their government-funded Maudsley Alcohol Pilot Project opened up an agenda centred on the therapeutic alliance between patient and helper. In this and other work, the researchers found that the helper’s commitment to working with drinkers (a key factor in alliance formation) depended on the workplace environment, including whether it engendered the feeling that this was a legitimate role supported by their organisation. Staff who felt that working with drinkers was ‘not my business’ could not be trained into being committed therapists. Cartwright’s studies turned the focus on the messages staff received about the organisation’s priorities as expressed in its policies, resource allocation, and the perceptions induced in staff about whether working with drinkers was a valued and worthwhile use of their time.

How to make a treatment service more effective

Here we turn the smaller but arguably more significant corpus of studies which have tried changing organisational practices and/or the commissioning context to see if these changes actually do improve performance – though performance is sometimes measured by proxy indicators such as retention in treatment rather than remission of substance use problems. In the process we will come across a bind which needs untangling – that services most in need of reform are likely also to be those unaware of this and not ready to improve.

There is tentative evidence that the introduction of performance contracts can improve provider performance and the effectiveness of services. These incentivise providers to shift their thinking from delivering units of service regardless of their impact on outcomes, towards delivering services which actually improve the clients’ condition and by doing so earn the incentives or satisfy the requirements of the contract. This is the way all substance use services were commissioned in the US state of Maine from 1992. Over a four-year period, effectiveness improved significantly across outpatient and residential programmes, though not for underrepresented or ‘difficult’ client groups. Though the contract specified required outcomes, it also required a certain amount of services to be delivered. Prior to the introduction of performance contracting, providers delivered more services than were contractually required; afterwards, they delivered close to the contracted amount. It seems providers were focusing on delivering the core services they were paid for, in place of delivering extra or ‘optional’ services clients previously had access to.

Adherence to a treatment protocol is a way of ensuring that treatment is standardised across the service, promoting consistently high quality. However, a tension arises if uniformity is enforced in the face of patient differences, as explored in this Effectiveness Bank hot topic about the individualisation of care. Local conditions too need to taken into account. Researchers monitoring the implementation of a structured behavioural therapy in rural Midwestern America found that therapists being trained in how to implement a new treatment intervention wanted to know how to implement the protocol in their specific setting, with their specific clients, under their specific organisational conditions. Before this, the therapists seemed to lack interest in the new treatment during training. Only when the research team tailored the implementation by responding to local conditions did therapists become willing and able to invest time and energy in learning to execute the protocol.

Administrative advances have enabled caring services to create and take opportunities to be caring in practice. A study of US services observed that intake assessments of patients’ needs were largely redundant paperwork which led nowhere in terms of meeting those needs. Linking assessments to a computerised guide to local welfare and medical services transformed them into a practical route to obtaining services matched to assessed needs – and treatment completion rates doubled.

Programme monitoring can be used to assess the quality and fidelity of interventions – how true they were in practice to the intended model. In this study of family-focused prevention programmes delivered in health care settings, programme fidelity improved over time, and a key conclusion was that fidelity assessment data can be successfully used to generate ongoing improvement in the quality of programme delivery.

Another way to hold up a mirror to a service is to use ‘walk-throughs’ – for senior staff to place themselves in the patient’s shoes and feel what is and isn’t working, rather than imagining all is well. That’s what staff did at 327 US services, as well as role-playing a relative of the client. An analysis of the ‘walk-throughs’ – which started with the first phone or other contact and extended to the early stages of treatment – showed that the role-players experienced poor staff engagement and impersonal interactions, shortcomings in equipment, administrative procedures and premises, poorly communicated information, burdensome and repetitive processes and paperwork, including lengthy intake interviews focused not on the client’s needs, but those of the agency, and failure to provide for clients with complex lives and problems. Extended to another 12 US areas, walk-throughs by senior staff became the key tactic for identifying service delivery problems and improving clinical processes.

Often the mirror through which an organisation can see reflected its strengths and weaknesses is constructed by an external agency to which treatment services must or choose to submit themselves for accreditation, but a review by two of the world’s most respected addiction experts judged accreditation a weak lever for improving outcomes. Instead the US experts favoured engendering motivation for change by subjecting agencies to market forces, of which in the UK the most prominent examples are ‘payment by results’ schemes which pay services for achieving certain outcomes. Such schemes are intended to force services to be effective or face financial penalties. They can force change, but sometimes only that required to gain the externally imposed carrots and avoid the sticks.

Going the extra mile

For any service improvement programme to work, the service has to engage in it and take it seriously. Australia’s internationally recognised addictions workforce development agency has pointed out that first an organisation has to want to change, yet the factors which mean a service is functioning poorly and failing its clients may also mean it is unaware of these deficits and that it neglects ways to improve. In the end it seems, it comes down partly to a service ethos which cares enough to take care that what it does and how it does it really does help its clients and patients One way to square this circle has been trialled in the USA, using staff surveys to alert the service to how its staff see it and how this compares with other services. Faced with the evidence, senior staff from agencies which scored as less open to change and to staff suggestions were the ones most likely to commit to change. However, the study did not assess whether they actually followed through on this commitment.

Ideally health services and charities whose mission is to serve will willingly open themselves to influence and scrutiny and embrace improvements, but the ones doing least well in that mission are probably also the ones least likely to take those steps. External pressure seems the solution, yet the same organisations may react by doing just what is needed to satisfy their funders or inspectors (which may bear a loose relationship to patient welfare) rather than engaging in a sustained improvement programme focused on the needs and aspirations of their actual and prospective patients. The market mechanism of patients voting with their feet is often not an option, increasingly less so as mega-services take over in local areas, offering to do everything for the commissioners. In the end it seems, it comes down partly to a service ethos which cares enough to take care that what it does and how it does it really does help its clients and patients.

Run this search for evidence that the organisation does matter, and for clues to how to make it more effectively service its therapeutic objectives.

Last revised 15 May 2016. First uploaded 01 August 2011

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