This entry is our analysis of a study considered particularly relevant to improving outcomes from drug or alcohol interventions in the UK. The original study was not published by Findings; click Title to order a copy. The summary conveys the findings and views expressed in the study. Below is a commentary from Drug and Alcohol Findings.

Links to other documents. Hover over for notes. Click to highlight passage referred to. Unfold extra text
Copy title and link SELECT AND COPY TEXT BELOW
Adult substance misuse statistics from the National Drug Treatment Monitoring System (NDTMS) 1 April 2015 to 31 March 2016
https://findings.org.uk/PHP/dl.php?file=PHE_45.txt&s=ssa&sf=sfnos
CLOSE | Comment/query | Tweet

Close chart

Close chart

Close chart

Close chart

Close chart

Close chart

Close chart

Close chart

Close chart

Close chart

Close chart

Close chart

Close Figures and trends for opiate users

First-time opiate users treatment starters plummet

The fall in the opiate-problem caseload and in patients starting/returning to treatment for these problems is overwhelmingly due to the fall in numbers starting treatment for the very first time – or at least, structured treatment of the kind recorded by the monitoring system. The steepness of this fall was remarkable, from 50,188 in 2005/06 to 6,598 in 2015/16. For every 100 patients starting treatment for opiate use problems ten years before, in 2015/16 just 13 did so. Unfold chart.

Close chart

Close chart

The figures for England start in 2005/06. UK-wide figures going back another two years (1 2) suggest that for numbers of new opiate use patients, 2005/06 was a turning point. For at least two years before, UK numbers (dominated by England) new to treatment for problems primarily related to opiate-type drugs were rising steeply, but then fell about as steeply. Unfold chart.

Methodology might have had something to do with the peaking of new opiate use treatment clients in 2005/06. The monitoring system which underpins both the English figures and the English component of the UK figures was new and finding its feet, so perhaps better recording partly accounted for the rises leading up to 2005/06. For example, compared to the year before, the relevant information on treatment history was recorded for 11% more patients overall, missing data having been reduced from 29% to 18% of records.

That does not detract from the remarkable drop in new opiate treatment clients from 2005/06, leaving an opiate use treatment population UK-wide and in England overwhelmingly composed of patients continuing in or returning to treatment. In 2015/16, 71% of opiate use patients in England were continuously in treatment from the year before and another 25% had returned to treatment after a break (which may have been in 2015/16 itself), leaving just 4% starting treatment for the first time in 2015/16.

There seem two broad explanations. One is the relative ‘stickiness’ of dependent opiate use and/or of its treatment. As Public Health England has commented, compared to other drugs the treatment history of the opiate use caseload “is indicative of heroin clients being more likely to drop out of treatment and to subsequently re-present, or to relapse after completing a treatment episode and to seek treatment again as a result.” The other factor is the waning in the uptake of heroin use in the general population, resulting in fewer new treatment clients and a progressively older and harder to treat opiate-using caseload, themes explored further below.

Opiate use treatment becoming less ‘successful’

Despite the recent policy emphasis on moving problem drug users through and out of treatment, since at least 2005/06 a stubbornly persistent three-quarters of opiate use patients in treatment at some time during the year were still in treatment at the end, and just a quarter had left, most without being recorded as having completed treatment and overcome their dependence. In 2015/16, just 10,463 left having recorded this apparent success, 7% of all those in treatment that year and 28% of all 38,007 who left treatment. It seems that nearly all these no-longer-dependent treatment completers notched up for their areas a further contribution to the important public health indicator of not just completing treatment successfully, but also not returning to treatment within six months – presumed indicative of no relapse to dependent opiate use and a lasting treatment success. Forming 6.72% of all opiate using patients in treatment in 2015/16, these estimated 10,067 patients were just 396 fewer than all no-longer-dependent treatment completers.

On these criteria considered above all emblematic of successful treatment, things have, however, been getting slightly worse. From a high point of about 9% of all opiate patients in 2011/12, in 2015/16 successful leavers in total and those not returning within six months formed just 7%. From that year too, successful departure also accounted for a diminishing proportion of all opiate users leaving treatment, steadily falling from 37% to 28% in 2015/16, while the ‘drop-out’ proportion increased from 22% to 35%. If we consider – as we well might (1 2) – being retained in treatment at year end as also indicative of effective treatment for opiate users, then over the same period the proportion of all possibly successful patients (by virtue either of being retained or leaving free of dependence) fell from a high point of 85% to 82% – still an improvement on 2005/06 and 2006/07. Unfold chart.

Close chart

Close chart

An ageing and more entrenched heroin-using caseload

For Public Health England, the explanation for diminishing success ( above) is an ageing and increasingly treatment-resistant opiate use caseload. A sign of the ageing phenomenon, in England the number of 18–24-year-olds starting treatment for opiate use problems for the first time or after a break fell precipitately from 11,351 in 2005/06 to 2,367 in 2015/16, while patients aged 35 or over rose from 19,086 to 25,897. Unfold chart.

Close chart

Close chart

It was a similar story among the entire treatment population, including those continuing in treatment from previous years, with the number of 18–24-year-olds with opiate use problems plummeting to a fifth of the numbers ten years before, down from 22,681 in 2005/06 to 4,491 in 2015/16, while corresponding patients aged 35 or more nearly doubled from 51,154 to 104,097. Unfold chart.

Close chart

Close chart

With older opiate-dependent people staying in or returning to treatment, and fewer younger people taking up the habit (at least, not to a degree or in a manner which results in treatment), in England and the UK in general the opiate-using treatment population is on average getting older. According to Public Health England (1 2), this ageing cohort is often in poor health, with a range of vulnerabilities associated with long-term drug use including social isolation and more entrenched, hard-to-treat addictions. As this implies, the persistence of dependent opioid use among patients in treatment should not be taken for granted or attributed to an inherent power of the drug. Persistence and relapse occur in the context of available treatment and social resources devoted to securing lasting remission and the limited recovery resources of dependent users of the kind driven or forced to seek formal help.

An ageing (and more entrenched?) heroin-using population

In turn treatment trends in England have been said to mirror general population trends consistent with an ageing population of opiate (mainly heroin) users who started using in the mid-90s or before. Because they are only partially being replaced by younger recruits, the result is an increase in the average age of problem opiate users in the general population – the trend thought to account for increases in drug-related deaths. Despite increases in the number of older problem drug users (representing mainly opiate users), the dwindling recruitment of new, younger users, has led to falls in the estimated total between 2004/05 and 2011/12.

Studies conducted between 2004/05 and 2011/12 which generated these conclusions defined problem drug users as users of opiates and/or crack whose use has brought them into contact with treatment services or the criminal justice system. The estimated number aged under 25 more than halved from 72,838 in 2004/05 to 32,628 in 2011/12. Over the same period, estimates for the numbers aged 35 to 64 rose from 114,459 to 152,127. Total numbers were estimated to have fallen from 327,466 to 293,879, and the number using opiates in particular from 281,320 to 256,163. Numbers injecting opiates or crack were also estimated to have fallen steadily from 137,141 to 87,302 (1 2). Unfold chart.

Underlying these trends was the reduced influx of new (and therefore relatively young) users of opiates or crack. Depending on the methodology, in England the reduction in numbers starting to use these drugs amounted to 20% or 45% between 2005 and 2013, when analysts could be confident that no more than 10,000 initiated use, a rate per 1,000 of the population 11 times lower than some local estimates from the epidemic years of the 1980s and early 1990s. However, from 2011 to 2013 the decrease ended and uptake estimates slightly increased, though the analysts could not be confident this was anything more than a flattening out of the previous decline. “If anything, the data suggest the downward trend is set to resume”, said the researchers.

To reach these conclusions they calculated the delay in entering treatment after starting opiate/crack use, finding that treatment initiates in 2004 and 2005 had typically started using six or seven years before at the peak of the spread of heroin use. However, by 2007 the pattern was changing; among that year’s treatment initiates, the peak period for starting treatment was just a year or two after starting to use the drugs. This trend solidified until for 2012’s treatment initiates, the mid- to late-90s hump in year of starting opiate/crack use was merely a small hill, and the dominant pattern was entry into treatment either the year of starting use or within two or three years. These rapid treatment entrants also tended to have started using the drugs beyond the typical 18–22 age range. One result was that the most common age of initiation of heroin/crack use among first-time treatment entrants rose from 18 in 2005 to 25 in 2013. Barring mistakes in the data, it seemed to the analysts that “There is a genuine shift towards new initiates being older, and for them to present to treatment much faster than in previous years.”

In the present context the significance of this finding is that even if the profile of opiate/crack use in the general population was unchanged, all else being equal the speeding up of treatment entry among older initiates into opiate/crack use would tend to increase numbers in treatment and increase the average age of the caseload. In other words, to a degree the ageing of the opiate use treatment caseload will be due not to the ageing of opiate users in the general population, but to older users starting treatment more quickly. This speeding up has obvious limits, so the effects on caseload numbers and age profile should flatten out.

Treatment engages most opiate/crack users but engagement of young falling relative to older users

The research analysed in the previous section enables us to calculate how many of the estimated population of opiate/crack users in England in a given year are in treatment – the treatment system’s performance at engaging its intended patients. In this respect, the opiate use treatment system based on prescribing of substitute drugs like methadone has internationally a creditable record, engaging well over half its potential patients.

The latest year for which we have population estimates is 2011/12, when 57% of the estimated 293,879 problem opiate/crack users were in treatment at some time, slightly down on the previous year but still well up on the 45% estimate for 2005/06. For opiates in particular (with or without crack), the proportion was even higher – 63%, again slightly down on the previous year but well above the 49% estimate for 2005/06. Unfold charts.

Broken down into age groups, population estimates set against treatment numbers show that part of the reason for the ageing of the treatment population has been a progressively greater ‘capture’ of older opiate/crack users and possibly a progressively lesser capture of the under-25s. By 2011/12 an estimated 62% of 35–64-year-old heroin/crack users were in treatment and 59% of 25–34-year-olds, but just 31% aged under 25. Over the years from 2005/06 the capture rate of the oldest group overtook that of 25–34-year-olds and the gap between the capture rate of these older heroin/crack users and those under 25 widened from perhaps just 11% to 29%. One reason ( above) could be that in the more recent years older initiates into opiate/crack use have increasingly been starting treatment more quickly than their younger counterparts. Relative to previous years, in the 2010s treatment seems to be becoming a choice made by older opiate users and one turned away from by younger users. Unfold chart.

Close Figures and trends for opiate users

Close Figures and trends for alcohol users

Alcohol treatment under-provided but success rate increasing

For alcohol treatment numbers there are at least three options: drinkers for whom this is their sole recorded substance use problem; those also recorded as problem users of other substances; and up to 2013/14, those treated primarily for drinking problems, who may secondarily be using other substances. The account below draws on all three figures. Before in 2009/10 alcohol treatment services were fully incorporated into the monitoring system, absolute numbers are an unreliable guide to the caseload, but there is no reason to believe that the proportional composition of the caseload will have radically altered as more services came on board.

How many drinkers are in treatment?

How many drinkers are in treatment depends on how these are defined. The highest figure for 2015/16 is 144,908, but for some of these patients their drinking was subsidiary to their drug use. In 2013/14 – the last year when alcohol treatment figures were separately reported – of the 155,381 patients whose substance use problems included alcohol, only 114,920 were being treated primarily for drinking problems. Applying the same ratio to 2015/16 suggests that around 107,174 patients were primarily being treated for their drinking. The same type of calculation, but based on numbers of patients with alcohol as their sole problem, results in a reassuringly similar estimate of 106,624 patients primarily being treated for drinking problems in 2015/16. Putting the two together, it seems a fair guess that the figure was about 106,900.

This can be refined down further to patients whose sole problem substance was alcohol, a number which peaked at 91,651 in 2013/14 and ended at 85,035 in 2015/16. The upshot is three figures for treated problem drinkers in 2015/16, ranging from 85,035 solely with a drinking problem, to an estimated 106,900 with a primary drinking problem but perhaps also using other substances, to 144,908 recorded as problem drinkers, including many for whom this was not their primary substance use problem.

Based on the highest version of the figures, since in 2009/10 alcohol treatment services were fully incorporated into the monitoring system, numbers with drinking problems have fluctuated around 150,000, peaking at 155,381 in 2013/14 and falling slightly in the next two years to end at 144,908 in 2015/16. Highlighted above is that by 2015/16 problem drinking patients were almost as numerous as problem opiate users. The gap closed due to the greater recruitment of drinkers into treatment rather than to their staying longer than opiate users, an issue explored below.

Alcohol treatment more of an in-and-quickly-out proposition

Problem drinkers (including those for whom this is a subsidiary drug) record a radically different treatment history to opiate use clients, the other largest group in the national caseload. New opiate use clients are scarce and most have continued in treatment from the previous year without a break in the focal year. Continuous treatment is much less common for drinkers and a far higher proportion are starting treatment for the first time. Relative to opiate use treatment dominated by maintenance prescribing, alcohol treatment dominated by psychosocial approaches is more of an in-and-quickly-out proposition.

Some illustrative figures are that while in 2015/16, 71% of opiate use patients were continuously in treatment from the year before, for problem drinkers it was 41%, a figure which has remained at around this level since 2005/06. The remaining roughly 60% either returned to treatment after a break or were first-time treatment entrants (how many were in each of these categories is not published). Unfold chart. Among patients prescribed medications in 2015/16, this treatment had lasted a year or more for 61% of opiate patients but for only 6% of the relatively few alcohol-only patients prescribed medications, for whom this would primarily have been an aid to short-term detoxification rather than longer term treatment.

Close chart

Close chart

Though ‘contaminated’ by the fact that just over 40% of the total alcohol caseload are also experiencing problems with other substances, the figures above show that treatment involving alcohol problems is in England quite different from treatment involving opiate use problems. A sharper distinction can be made by focusing on the (since 2005/06) just over 60% of the problem drinking caseload for whom this is their sole recorded substance use problem. Only for the last two years of the figures do we have a breakdown equivalent to that for opiate users. In those years, 31% of patients were starting treatment for the first time and 31% and 32% were continuously in treatment from the year before. The contrast with corresponding figures for opiate user is extreme; in 2015/16 just 4% were starting treatment for the first time and 71% continuously in treatment from the year before.

For alcohol-only patients, numbers of first-time treatment starters have been published back to 2005/06. Among these patients solely with a drinking problem, since 2008/09 the trend in first-time starters has been downwards both in numbers and as a proportion of the alcohol caseload, from 33,709 down to 26,111 and from 45% to 31%. The proportion was at its peak in 2005/06, when nearly half – 47% – of all alcohol-only patients in treatment were recorded as experiencing this for the first time. Since then, increasingly the caseload has been continuing in or returning to treatment. Unfold chart.

Close chart

Close chart

Alcohol use treatment becoming more ‘successful’

Another contrast with opiate use treatment is that the treatment of patients solely with a drinking problem has on criteria set for public health nationally been more successful, and since 2011/12 yet more successful, as the success rate with opiate patients has declined.

Reinforcing the impression that relative to opiate use treatment, alcohol treatment is more an in-and-out process, since at least 2005/06 in all but two years most alcohol-only patients have left treatment during the year rather than still being in treatment at the end, and since 2012/13 the proportion has neared two-thirds, falling only slightly to 63% in 2015/16. Of these leavers, in 2015/16, 62% were recorded as having overcome their dependence on alcohol, forming 39% of the total caseload compared to 7% of opiate patients.

Since 2005/06 the numbers and proportions of alcohol-only patients leaving treatment free of dependence have both been increasing. The numbers rose from 24,862 in 2009/10 to 33,203 in 2015/16, having peaked at 36,164 in 2013/14. As a proportion of all alcohol-only patients, the increase was from 18% in 2005/06 to 28% in 2009/10 and 39% each year from 2012/13. As with opiate patients, we know from other figures that nearly all these no-longer-dependent treatment completers notched up for their areas a further contribution to the important public health indicator of not just successfully completing treatment, but also not returning within six months, presumed indicative of lasting treatment success. Non-returners formed 38% of all alcohol-only patients in treatment in 2015/16 – in numbers, about 32,619 patients, just 584 fewer than all no-longer-dependent treatment completers. Unfold chart.

Close chart

Close chart

Alcohol caseload also ageing

The typical age of problem drinkers in treatment (including those also using other drugs) has been increasing. From 27% of the caseload in 2005/06 and 32% in 2009/10, by 2015/16 the over 44s constituted 42% of all drinkers in treatment, increasing in numbers from 46,996 in 2009/10 to 60,299 in 2015/16. In contrast, over the same period numbers aged below 35 fell from 52,706 to 39,625. Unfold chart. The caseload whose sole problem is drinking are older still. In 2014/15 and 2015/16 – the only years for which figures have been published – most were 45 or over, 52% and 53% respectively. Public Health England has warned that many of these people will have been drinking at high-risk levels for some time and are likely to be experiencing illnesses such as liver disease and high blood pressure.

Close chart

Close chart

The age breakdown of problem drinkers starting treatment either for the first time or returning was very similar to that of all patients in treatment. In 2015/16, as with the total caseload, 42% of patients with a drinking problem (including those also using other drugs) were aged 45 or more and just 7% were below 25 years of age. Also as with the overall caseload, treatment-starters have been increasing in age. Back in 2005/06, 27% were aged 45 or over and 14% were below 25 years of age, respectively about half and double the proportions recorded ten years later. Unfold chart.

Close chart

Close chart

Ageing of the opiate use treatment caseload has been linked ( above) to the waning success of that treatment as assessed by successful treatment completions. The explanation put forward by Public Health England is that ageing signifies an increasingly treatment-resistant caseload with more entrenched problems. However, similar trends among the problem drinking caseload have coincided with increasing treatment success as assessed by the same measures above. Perhaps relevant is that the kind of ill-health associated with many years of heavy drinking such as liver disease and hypertension gives drinkers reasons to cut back because alcohol is a direct contributor and cutting back will help. In contrast, heroin does not directly cause serious illness and cutting back on its use will not necessarily alleviate accumulated illnesses associated with a drug using lifestyle. Heroin and its legal substitutes are also highly effective at relieving pain, anxiety and discomfort; illnesses which cause these complaints may give users reasons to continue using illegal opiates and/or legal substitutes.

Ageing population of dependent drinkers

Setting the context for treatment trends, a regular if infrequent national survey of mental health has provided data on the prevalence of dependent drinking among the general household population in England. Based on a score of at least 16 on the AUDIT questionnaire (indicative of harmful drinking or mild dependence or worse), the 2014 report concluded that across the years 2000, 2007 and 2014, at 3.4% to 3.8% of the 18+ population, “Overall, levels of harmful and dependent drinking have remained stable.”

But within the overall stability there were signs that such drinking patterns had become more common in older people, most clearly the 55–64-year-olds, among whom the proportion doubled from 1.4% in 2007 to 2.8% in 2014, but also among 45–54-year-olds where it rose from 2.0% to 2.4% and finally in 2014, to 2.8%. At the same time such drinking became less common among 16–24-year-olds (falling from 6.2% to 4.2%) and among 25–34-year-olds (falling from 5.2% to 4.4%). The pattern fits that of the overall treatment population and of treatment starters, among whom older age groups also became more prominent and younger patients fewer above.

1 in 5 dependent drinkers in treatment

Based on the same national survey, it has been estimated that in 2014 there were 595,131 adult dependent drinkers in England potentially in need of specialist treatment, about 1.4% of the same-age population – an estimate subject to considerable uncertainty. The estimate was based not just on suggestive evidence from AUDIT scores, but also confirmatory evidence from a questionnaire intended to assess alcohol dependence. Specifically, respondents had to score:
• 16 or more on AUDIT (harmful drinking and/or mild dependence or worse) and 16 or more on the Severity of Alcohol Dependence Questionnaire (at least moderate dependence); or
• 20 or more on AUDIT (probable dependence) and 4 or more (at least mild dependence) on the dependence questionnaire.

During the corresponding financial year (2014/15), treatment engaged 150,640 people whose substance use problems included alcohol and 89,107 whose sole problem was drinking. The year before 114,920 patients had cited alcohol as their primary problematic substance and 91,651 as their sole problem substance, suggesting that in 2014/15 there may have been 111,730 patients treated primarily for a drinking problem. How many of these were dependent is not recorded. Assuming all were, it means that 19% of all the estimated population of dependent drinkers in England were in treatment at some time during the year. Of this population, survey responses indicated that 57% might consider treatment on the basis that they expressed some desire to cut down, amounting to 341,376 adults. The treatment caseload was equivalent to about a third of this number.

Another way of estimating treatment-need put forward by the National Institute for Health and Care Excellence excluded low scorers on the dependence questionnaire, requiring scores (16 or more) indicative of at least moderate – not just mild – dependence. The result for 2014 would have been a much reduced figure for the dependent population of 257,626. The estimated treatment caseload with a primary alcohol problem (111,730 patients) is equivalent to 43% of this figure. This variant in ways of estimating the number of drinkers who might warrant treatment is not the only one. On some grounds the population who might be considered in need of (even if only brief) treatment would be larger still, or those almost certainly in need of structured, care planned treatment, smaller still.

The argument has been made that the method which yielded for 2014 an estimate of 595,131 adult dependent drinkers best embodies NICE guidance on who should be offered treatment. If this is the case, treatment is engaging the equivalent of about 1 in 5 of those whom official guidance suggests are in need of treatment. This figure based on what survey respondents living in private households are prepared to admit to is almost certainly too optimistic. To the 595,131 adult dependent drinkers found by this method must be added dependent drinkers who are homeless (estimated at 19,328 in 2012) and an allowance for the tendency of survey respondents to underplay their drinking and related problems.

Close Figures and trends for alcohol users