Drug Treatment Matrix cell B3: Practitioners; Medical treatment

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Practitioners; Medical treatment

Seminal and key research and reviews on the influence of the practitioner in the medical treatment of drug dependence. Investigates the how clinician-patient relationships might be affected by enforcing clinic rules and the potential importance of doctors forming a “whole person’ relationship with patients.

S Seminal studiesK Key studiesR ReviewsG Guidancemore Search for more studies

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S Quasi-randomisation reveals methadone counsellor is an ‘active ingredient’ (1988). Effectively random allocation of patients to different methadone counsellors at the same service revealed that effective counsellors were more diligent and active, helping patients anticipate problems and solutions. Related study below. For discussion click here and scroll down to highlighted heading.

S What makes a methadone counsellor effective? (1985). In US study based in a methadone treatment clinic differences in effectiveness could partly be explained by the personalities of the therapists, particularly their abilities to quickly form warm, supportive relationships with patients.

K Treatment staff matter as much as the drug (1999). Trio of US studies finds methadone patients do better with active counsellors who respond constructively to their problems. One of the three was the study below.

K Quasi-random allocation exposes impact of methadone counsellors (1999). When methadone doses had been tailored to the individual and stable for at least three months – effectively taking them out of the equation – US study found which counsellor the patient had effectively at random been assigned to substantially affected retention and illegal substance use. One of three studies featured in entry above. Related study above. For discussions click here and here and scroll down to highlighted heading.

K Patients more likely to avoid illegal opioid use when relationship good with methadone-prescriber (2014). Of all the assessed variables, whether six months in to treatment patients in France felt they had a good relationship with their doctors was most closely related to the elimination of non-prescribed opioid use six months later, possibly because it meant they were more likely to discuss their dose with their physician and therefore to be prescribed appropriately. For discussion click here and scroll down to highlighted heading.

K Patients do best with GPs who they feel know them as a whole person (2007; free source at time of writing). US patients referred to primary care after detoxification reduced drug use/problems most when they saw GPs who they felt knew them as a whole person and who consistently saw them rather than referring to a colleague or assistant. Related study below. For discussion click here and scroll down to highlighted heading.

K Not just an addict/patient (2007). Free source at the time of writing. Interviews with long-term buprenorphine maintenance patients in France revealed that “the physician’s behaviour may convey to the user that s/he is … a life-long junkie or a repentant junkie, or on the other hand may allow him to see himself as a whole person,” promoting “a positive worthwhile image free of the stigma of the junkie”. Related study above. For discussion click here and scroll down to highlighted heading.

R Clinicians’ impact on treatment quality (2000; free source at the time of writing). Assessed whether retention and substance use outcomes were related to the clinician’s professional status, whether they had been a problem substance user, their adherence to protocols, countertransference, formation of therapeutic relationships with patients, personality, beliefs about treatment, and professional practice issues. Found that clinicians vary greatly in their performance but that “past assumptions that levels of training, experience, or other simple therapist variables could account for such differences does not hold”. For discussion click here and scroll down to highlighted heading.

R Above all, don’t do the wrong thing (2015; free source at the time of writing). Across health care in general, doctor-patient interactions that are invalidating (do not successfully communicate acceptance and understanding) damage relationships more powerfully than positive communications cement them. More on the importance of not doing the wrong things in cell B2.

G What UK doctors should do and be able to do ([UK] Royal College of Psychiatrists and Royal College of General Practitioners, 2012). Guidance from UK professional associations for GPs and for psychiatrists on the competencies, training and qualifications expected of doctors involved in caring for substance users, from generalists such as doctors in emergency departments and general practitioners to addiction specialists.

G What UK specialist addiction doctors should do and be able to do ([UK] Public Health England, Royal College of Psychiatrists and Royal College of General Practitioners, 2014). Guidance from body overseeing addiction treatment in England and from professional associations for GPs and for psychiatrists on the “essential functions which can usually only be carried out by addiction specialist doctors” and the importance of retaining their expertise in the sector.

G Competencies for working with co-occurring substance use and mental health problems (2019). From Clinks, a national charity supporting voluntary organisations in the criminal justice system in England and Wales, and developed through Public Health England based on their related guidance. Advice on the values, knowledge and skills required for effective care of people whose substance use problems are complicated by poor mental health. Informed by patients who emphasised the “importance of workers’ personal qualities and behaviour and how vital the workers’ characteristics were to an individual’s recovery journey”.

G What US specialist addiction doctors should do and be able to do ([US] American Society of Addiction Medicine, 2014). Consensus guidelines from the US professional association for doctors who specialise in treating addiction on what they are expected to do and the standards they should meet throughout treatment from assessment to aftercare.

Search for all relevant Effectiveness Bank analyses or search more specifically at the subject search page. See also hot topic on the influence of treatment staff.

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What is this cell about? About the treatment of dependence on illegal drugs in a medical context and/or involving medical care, typically by GPs or hospital drug treatment units. Clinical staff are responsible for medications, so the centrality of these to an intervention marks it most clearly as medical. Medications may be intended to help patients withdraw from drugs, sustain longer term abstinence, or to replace the drug the patient is dependent on with a prescribed drug of the same kind but which can be taken more safely, enabling social stabilisation and protecting health.

Medications are, however, never all there is to medical care. Even when they seem to be all there is, that in itself sends a message to the patient about how they are seen and valued by the service. Founded on a good relationship with the prescriber, effective prescribing requires the collaboration of the patient to stay in or complete treatment and help choose the medication and set an appropriate dose by disclosing their use or non-use of the medication, how they have reacted to it, and their non-prescribed drug use, while appropriate provision of ancillary support depends on a frank admission of needs. In particular, how long patients stay in treatment is related to the quality of their relationship with clinical staff, and retention is the main factor in the effectiveness of ‘maintenance’ treatments such as methadone maintenance.

In these ways, relationships with staff may affect (study listed above) outcomes indirectly because they enable more or less appropriate prescribing and broader help. Interactions with staff are also in themselves potentially therapeutic, and medical care may consist entirely of advice and psychosocial support. These are among the reasons why of medical care in general, it has been said that “ ‘talk is the main ingredient … and it is the fundamental instrument by which the doctor-patient relationship is crafted and by which therapeutic goals are achieved’. From this viewpoint, a good interpersonal relationship can be regarded as a prerequisite for optimal medical care.”

The relationship-forming qualities of treatment staff are much less easily manipulated by researchers and less commonly researched than the intervention. Studies usually have to rely on an association between relationship quality or staff attributes on the one hand, and retention or substance use on the other, rather than deliberately allocating patients to workers known to differ along these dimensions. This makes it difficult to be confident that relationship quality or staff attributes actually caused any differences in outcomes, rather than the reverse, or both ends of this supposed causal chain not being cause and effect at all, but related to other, more active ingredients.

Relevant specifically medical studies are few, but for further studies possibly as relevant to medical care turn to the cell dealing generically with practitioner influences.

Where should I start? With this freely available review listed above, still a valuable introduction to the issues. It systematically runs through evidence on the possible reasons why patients do better with one clinician than another. The reviewers comment that such effects often emerge from studies not designed to find them, sometimes being strong enough to surface through the study’s attempt to eliminate ‘extraneous’ influences. Relative neglect by research is contrasted with the everyday experience of front-line clinicians, managers and patients, for whom it is “obvious … that some practitioners are highly regarded whereas others are avoided”. The reviewed research reveals that “clinicians typically account for more [of the difference] in patient outcomes than do differences between active treatments or patients’ baseline characteristics”.

If clinicians are important, the next question is, ‘Why?’ – one the rest of this ‘bite’ addresses more fully. The review examined research relating retention and substance use outcomes to (among other potential influences) the professional status of the clinician, whether they are an ex-addict, their adherence to protocols, emotional reactions to patients, personalities, beliefs about treatment, and interpersonal functioning. What did not account for differences in clinicians’ impacts were professional characteristics, including qualifications and whether they were former problem substance users. According to the reviewers, instead the most consistent influence has been the clinician’s ability to build a positive relationship with patients, one best identified in practice: “Select and evaluate clinicians based on their ‘track record’ … assumptions that levels of training, experience, or other simple therapist variables could account for such differences does not hold. Selecting and evaluating clinicians based on how they actually perform, using standardised measures, is rarely done but is an effort that could greatly improve the quality of care.”

Highlighted study Philadelphia in the USA was the site one of those serendipitous accidents which expose previously obscured influences – the sudden resignation of two counsellors at a methadone service. Their caseloads were reassigned effectively at random to remaining counsellors, offering the opportunity for a seminal study listed above to assess whether the four allocated at least a dozen of the 61 clients altered the trajectory of their progress from the six months before to the six months after. Not only did this permit the counsellors to be compared with each other, it also meant pre-transfer measures could be used to assess how patients changed, not just where they ended up. Clinic records were the data source in this study, led by an eminent US researcher later to become an adviser on addiction treatment to Public Health England.

Before the transfer each of the sets of patients later allocated to the four counsellors was spread across the two counsellors who left, and each set was doing about equally well. After the transfer, each set was in the hands of a single counsellor, and the impacts were substantial. Despite higher methadone doses and more of their patients being prescribed other medications, those transferred to the least effective counsellor worsened in their drug use, arrests and employment. In contrast, over a six-month period the most effective counsellor was able to bring patients to the point where their non-prescribed drug use was virtually zero and employment significantly improved, while at the same time substantially reducing their doses of methadone and the proportion prescribed ancillary medications.

Differences between patients and the qualifications of the counsellors did not account for the findings, which were also reflected in their prior caseloads; before and after the transfer, they consistently differed in how well their patients did. Case-notes indicated that the more effective counsellors took a well-organised and diligent approach to care planning, documentation and clinic rules, suggesting that good organisation is a fundamental platform for everything else, including relationship-building. The stand-out counsellor built on this platform, anticipating patient problems and discussing strategies to deal with them in advance, focusing counselling on the development of new behaviours and new ways of thinking. He or she was not only administratively diligent, but actively problem-solving and therapeutic. The authors speculated that this enabled them not just to have better outcomes, but to achieve these with less medication and less use of street drugs by their patients.

This was one small – if virtually unique – study, but the proposition that methadone counsellors (the same seems true of the prescribing physician) alter the prospects of their patients is confirmed by another larger US study involving 265 patients and 13 counsellors, which took advantage of what was said to be the random allocation by the clinic of patients to counsellors. Importantly perhaps, the clinic in this study comprehensively assessed each patient to determine and adjust the dose of methadone, which had been stable for at least three months, effectively taking dose out of the equation and enabling other influences to more strongly emerge. One which “clearly stood out” was that “some counselors obtained better results than others” in terms of the illegal heroin and cocaine use of their patients.

Issues to consider and discuss

What do rules do to relationships? Consider this quote from an article listed above and described in the previous section: “Methadone dose … has been given too much emphasis … the interpersonal processes involved in a working alliance with the substance-abusing patient and the assigned therapist has been given too little” – a conclusion based on the finding that counsellors significantly differed in their effectiveness, yet not because they authorised higher doses for their patients. Another study found (summary above) that the best counsellor in the study actually reduced doses relative to counsellors who did less well. Sufficient dosing is one of the most solidly established success factor in methadone maintenance. If relationships are as important, then they are very important.

It may, however, be false to ask which is the greater influence, because dose and relationships almost certainly interact. Relationships could act partly through dose, permitting patients to feel they can be honest and open and enabling prescribers to flexibly adjust dose in response to those messages, at least as important as the average dose level across a caseload (1 2). The interaction might work the other way too: patients who get the doses they feel they need are likely to be easier to form relationships with and more positive about the clinic and the staff responsible for their care.

However it happens, if relationships are important, that means influences on relationships are important too. In methadone programmes, the most obvious are the sometimes unpalatable requirements imposed through keyworkers and doctors, including patients having to come to the clinic or pharmacy nearly every day to swallow their methadone in front of staff, and regular urine tests to spot non-prescribed drug use. Both (see for example an evaluation of supervision) have their justifications, but both too are easily seen as signs of a lack of trust in the patient: in the case of supervision, that they will take their medication as directed rather than selling or otherwise ‘diverting’ it; and in the case of testing, that their reports of their (non-)substance use can be believed. Supervision also forces the patient into what they may feel to be a stigmatising position, exposed as a drug user in the pharmacy. When consumption is supervised at the treatment site, it can contribute to making visits there a dehumanising experience. In regard of drug tests, the humiliation is obvious if it is felt that the submission of urine specimens has to be observed to prevent ‘cheating’.

Current UK clinical guidelines acknowledge several valuable roles for urine testing but try to reduce it to a minimum and to make the undignified process of watching patients provide the specimen very much the exception, and then only with informed consent. “Many patients will,” say the guidelines, “admit to continued drug use without the need for repeat testing, especially if they are clear that this information is welcomed positively with concern rather than with any disappointment or frustration.” Effectively the guidelines construct a virtuous circle: trust in how the clinician will react maximises voluntary disclosure and minimises the need for trust-eroding drug tests.

The guidelines are also relatively (eg, in comparison with the USA and Australia) relaxed about supervising consumption, largely leaving it to clinical discretion. Without stipulating this, they recommend that in most cases it will be appropriate for new patients to be required to take their daily doses under the direct supervision of a professional for a period of time to allow monitoring of progress and ongoing risk assessment. How long supervision lasts should, say the guidelines, depend on assessed clinical need rather than arbitrarily determined. This step back from the three months’ supervision previously recommended – a stipulation for which there is no evidence (1 2) – opens up the space for clinicians to give individualised reasons for supervision, making it a matter for discussion rather than imposition.

How do the patients see this unusual requirement to take their medication under the eyes of clinic or pharmacy staff? They may accept the rationale for supervision at the start of treatment, but more extended supervision is generally unpopular (1 2 3 4). Doctors know patients find supervision aversive, so exploit its relaxation or imposition to manipulate how patients behave; in Scotland, 20 out of 32 clinicians said they did this, and 13 felt supervision led some patients to drop out prematurely. Supervision also entails near-daily attendance at the prescribing clinic or pharmacy, in itself an unpopular requirement.

How do you think imposition of these requirements might affect relationships with keyworkers and doctors? Can they be implemented in a sensitively skilled way which does not undermine the vital communication channel with the patient? From the Highlighted study described above, it would seem so; remember all the most effective counsellors were diligent in this respect as in others. How might they have defused this potential source of friction?

Not just an addiction In this section we examine something which ought to be important, but for which in the context of the medical care of drug dependence, the evidence is slim. It is the adoption by the clinician of a ‘whole person’ approach to working with patients, in health and mental health (1 2) generally, a principal component of patient-centred care and a recovery orientation, especially for people with multiple and complex needs. It was there strongly among the attributes mental health service users wanted changed in their clinicians – their “failure to take account of all domains of a person’s life; focus on symptoms and illness; … failure to see the ‘whole person’ ”.

Responding to patients as whole person means responding to their complaint in the context of its relationship to them as multi-faceted human being with other problems, strengths, interests and identities, even if in the case of drug dependence these may have been subjugated to their need to finance, find, and take illegal drugs. Effective treatment relieves these needs, opening the way for suppressed and new identities to flourish. As we’ll see, whether they do flourish seems to depend partly on relationships with clinical staff.

Why a whole-person approach ought to be important was explained in cell A2, where it was pointed that for behaviours as socially unacceptable as heroin or cocaine dependence, “by the time you have narrowed down to the minority who try these drugs, the very few who become regular users, the fewer still who become clinically dependent, and finally the subset who want to stop but feel they can’t without treatment, then you have sifted down to a highly atypical and usually multiply disadvantaged and/or troubled population … whose drug use is entangled with social, economic and psychological features which unless addressed repeatedly precipitate them back into dependent substance use.” That constellation seems to demand holistic support, and that demands assessing and understanding the person as a whole.

Creating a new identity is an important task in avoiding a return to addiction

There is another reason too. 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). In cell E2 we argued that “Making substance use central to a person’s identity is not necessarily the best way to help them de-centralise from substance use”. Instead of being something they do among others, users of illegal drugs are reinforced in seeing their drugtaking as central to their identity because this is how they are treated by people and institutions with power over their lives, among whom are treatment staff who control access to medications and broader support. If the patient is led to see themselves as nothing but a ‘junkie’, the route to recovery is likely to be that much harder.

These concerns may be particularly applicable to medical care. With just a few minutes to spare in a typical consultation, and the tendency of medical training to generate a focus on “techniques and procedures”, issues like adjusting the medication regimen may be all that are seriously addressed.

So much for the theory, what of the evidence? From France we have evidence that for patients the distinction between whole-person and more limiting relationships with doctors is a reality, emerging (study listed above) in interviews with long-term buprenorphine maintenance patients. Four relationship patterns were identified, focused on: dose; compliance with treatment; drug prescription; or on the person – a whole-person approach. The first three were characterised as consigning the user to a “lifetime identity as a junkie”, to being a compliant ex-addict patient, or acting the role of a compliant patient to obtain drugs. Only the whole-person relationship promoted “The redefinition of self in an identity released from the stigma of drug dependence,” making it possible for the user to “express himself/herself in the relationship as a person in his/her own right”. Unfold Unfold supplementary text the supplementary text for more on how these kinds of relationships were seen by the patients and their advantages and limitations.

If the distinction between whole-person and more circumscribed doctor-patient relationships is a real one, what are the consequences? Here we run up against the difficulty of disentangling cause and effect. It may, for example, be that rather than promoting recovery, such relationships form because the patient is already doing well, and there is less need to focus on compliance, stabilisation and control. With that caveat, the search for consequences takes us to at least three studies. Unfold Unfold supplementary text the supplementary text to read about what they found.

The three studies are suggestive but cannot be definitive about the consequences of a whole-person relationship. If these consequences are real, almost certainly they are overshadowed by the effects (for example) of being offered versus denied effective pharmacotherapy, though they may help that pharmacotherapy be effective by keeping patients in treatment, taking the medication, and feeling able to be frank with their doctors about the dose they need and how it is best dispensed. Whether on its own a whole-person relationship with a doctor can be therapeutic is untested, and testing it may be unrealistic because it would require the blanket standardisation of other aspects of care, in itself antithetical to a whole-person relationship. It is one example of how what may be quite important cannot easily be proved.

Given the evidence we have, your own experiences as a patient (not necessarily in addiction treatment) and perhaps as a doctor, and your experiences of addiction treatment services, how would you rate the importance of what we have short-handed as a ‘whole-person’ relationship? Nice, but not an active ingredient in medication-based recovery, a diversion from the technical care and prescribing which are the active ingredients, or essential to optimising the care of complex cases?

Thanks for their comments on the original entry in draft to James Bell of the National Addiction Centre in London, England. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

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