National Treatment Agency for Substance Misuse.
[UK] National Treatment Agency for Substance Misuse, 2011.
England's National Treatment Agency for Substance Misuse argues that the efforts of users, workers and service providers to put recovery at the heart of treatment are paying off in the form of more drug dependent patients successfully completing and leaving treatment and not having to return after relapse.
Summary This is one of a series of reports from the National Treatment Agency for Substance Misuse – a special health authority which aims to improve treatment for drug problems in England – presenting a picture of this treatment based on data from the National Drug Treatment Monitoring System.
The report highlights that despite the typically long-term trajectory of treated addiction featuring multiple relapses, figures for England for the financial year 2010/11 record that 27,969 adults left treatment free of dependence – 18% more than 2009/10 (23,680) and 150% more than 2005/06 (11,208). At the same time, fewer drug users are starting treatment. From a peak of 84,520 in 2008/09 this fell to 79,255 in 2009/10 and then further to 74,028 in 2010/11. Also waiting times have improved: 96% waited no more than three weeks for treatment in 2010/11, compared to 94% in 2009/10 and 93% in 2008/09.
These numbers tell us that while fewer users are coming into the treatment system, they are being seen quicker and more are overcoming addiction, affording them the potential for a full recovery.
This annual snapshot of figures has been augmented by six years of robust drug treatment data, tracking amongst other things whether patients remained in treatment, had to return after leaving, or had left and not returned in subsequent years. It revealed that 255,556 adult drug users entered treatment for the first time from April 2005 to the end of March 2011, mainly for heroin addiction. By the end of this period 84,179 or a third were (still) in treatment, either because they had stayed continuously or left and returned. The remainder were no longer in treatment at the end of the six years; 71,887 or 28% of the total had successfully completed their treatment, while 99,490 or 39% had left without completing their treatment programmes.
These figures reflect the often unpredictable nature of drug dependence and the ongoing cycles of relapse and remission. But they also show that the more recently someone started treatment for the first time (ie, 2009 compared to 2005), the more likely they are to complete it successfully. Additionally, drop-outs and relapses are falling. More drug users are recovering from addiction, fewer need treatment, and those who do need it are getting over their addiction quicker.
A closer look at these figures shows that most drug users recover within the first two to three years of starting treatment, leading us to the speculation that this may amounts to a 'window of opportunity' during which addiction can most often successfully be treated, though many continue to recover after longer periods.
Heroin remains the most common drug patients seek help either with or without also having problems with crack cocaine, though both categories have been falling since 2007/08. Fewer treatment starts for heroin and/or crack dependence echoes estimates from the Centre for Drug Misuse Research at the University of Glasgow, that from a peak of 332,090 for 2005–2007, the number of problem heroin and crack users fell by 2009–2010 to just over 306,000.
While the decline in heroin and crack use especially among younger adults is encouraging, their cannabis use remains a concern. It is the only drug in respect of which increasing numbers of young adults are coming into treatment. In 2009/10 it overtook heroin (without other drugs) as the biggest category of drug for 18–24s coming into treatment; the following year the respective figures were 4493 for cannabis and 3253 for heroin. This does not necessarily mean more young adults are using cannabis – indeed, the British Crime Survey suggests fewer are. Instead, the rise may reflect increased priority given to cannabis by the treatment system and stronger strains of the drug creating more problems. Also, the marked fall in heroin treatment numbers has freed capacity within the system to treat young people using cannabis.
These figures reveal an overall picture in England in 2010/11 of declining drug use more or less across the board, fewer drug users coming in for treatment, and better results for those who do. Together, these trends are cause for us to be optimistic that the drug treatment system can continue to meet demand and help more people to recover from drug dependence. The efforts of users, workers and service providers to put recovery at the heart of treatment are paying off.
However, this optimism must be tempered by caution. These trends are still in the early stages and it will be several more years before we can be confident we are seeing a sustained decline both in addiction and treatment demand. Furthermore, changing patterns of drug use are unpredictable and often take some time to manifest themselves in the treatment system. We also face a huge challenge in continuing to tackle the problem of older, entrenched drug users who find it difficult to make progress through the treatment system.
In the meantime the system, and those who work in it, must remain focused on sustaining the increases in the number of drug users who complete their treatment successfully, and on giving everybody who needs help the ambition and best opportunity to recover from dependency.
commentary These encouraging statistics should be seen in the light of what for the National Treatment Agency for Substance Misuse constitutes 'successfully completing' treatment (1 2). As reported by the treatment service from which the patient last exits, this means they are no longer seen as requiring structured drug treatment, and have left treatment (not just that service, but the system as a whole) no longer dependent on any drug, and not using opiates or crack cocaine. They may be using other illicit drugs in a non-dependent manner and may be drinking and smoking to any degree. Unlike the definition of a few years before, planned referral to another treatment service is not counted, as the patient remains in the treatment system.
The argument that increasing numbers of successful completions is evidence of increasingly successful treatment rests partly on an analysis of patients leaving treatment for drug problems in 2005/06. Over the next four years, 57% who left having successfully completed avoided being officially recorded as problematic users of illegal drugs, neither being picked up by criminal justice system nets intended to identify problem drug users, nor returning to treatment on their own initiatives. This record of 57% seemingly staying recovered from their dependence compared with a figure of 43% among patients who left without having successfully completed treatment. The difference of 14% is appreciable, but not as large as would be expected if successful completion correlated strongly with successful treatment in terms of lasting recovery. Nevertheless it is enough to justify conclusions based on the assumption that successful completion is a better outcome than patients leaving treatment before the service considers them free of dependence and/or use of heroin or crack cocaine.
Whether successful completion is also a better outcome in terms of crime and health than staying in treatment – the usual situation within each year – is less certain. In terms of reduced convictions and presumably reduced crimes, another report from National Treatment Agency for Substance Misuse records that for patients convicted in the two years before starting treatment, the greatest reductions were among those continuously in treatment for the next two years, though successful treatment leavers were not far behind (47% v. 41%). However, these figures combine big differences in the types of patients who stay and leave treatment early. When the focus was narrowed to opiate/crack users, among whom successful completers and retained patients had a virtually identical pre-treatment conviction rate, the gap widened to 10% (46% v. 36%).
The chart in the report illustrating the rise in the proportion of new patients leaving the treatment system having successfully completed their programmes appears to confound changes in that proportion over a given follow-up period, with the longer time available to patients from earlier years to by the end of 2010/11 relapse or get to a stage in their treatment and addiction careers when they lastingly retire from both.
A trend to a higher proportion of patients each year successfully leaving treatment and not returning could be partly due to the aging of the adult treatment population. In 2005/06, 73,217 were under 30 and 32,406 aged 40 or more. By 2010/11 the under-30s had shrunk to 60,578 but the 40+ groups had expanded to 58,617. More people at the stage in their lives when they have had enough of the rigours of the dependent use of illicit drugs and/or of the demands and restrictions of being in treatment would translate in to a higher proportion successfully completing treatment as defined by the National Treatment Agency for Substance Misuse. It is possible that improved treatment access contributed to the aging by enabling earlier exits for a higher proportion of the younger dependent users newly entering treatment in recent years. It is also possible instead that (as the featured report speculates) heroin and crack have lost their appeal among some of the young people who ten years ago might have become involved in their use.
Without making any specific reservations about the featured report, it should also be borne in mind that analysts with an interest in the success of a programme they are evaluating tend to produce more positive analyses than independent analysts – in research terms, the
In several social research areas,1 programme developers and other researchers with an interest in the programme's success have been found to record more positive findings than fully independent researchers.
1. See articles at the following web addresses:
It is part of the remit of the National Treatment Agency for Substance Misuse to have an interest in the success of addiction treatment in England, to improve this, and to show this has been done by producing reports such as the featured report.
Thanks for their comments on this entry in draft to Marion Morris of the London Borough of Haringey and NHS North Central London. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 27 June 2012
STUDY 2013 Drug treatment in England 2012–13
STUDY 2014 Drug treatment in England 2013–14
DOCUMENT 2011 Substance misuse among young people: 2010–11
DOCUMENT 2012 Substance misuse among young people 2011–12