FROM METHADONE TO RECOVERY – The British government plans to change drug treatment in a drastic reorientation away from harm reduction.

Drug addicts will now receive help in overcoming addiction rather than primarily seeking to reduce the harm caused by drug use which was the main emphasis of the previous government’s policy.
In the future, substitution treatment will play a “limited role” while fighting addiction will become the overriding treatment objective.

James Brokenshire, the Drugs Minister tells Daily Telegraph that “there should only be a limited role for methadone in treatment. “[Methadone] should be seen as part of a pathway taking people to a position where they are clear of addiction.”

The policy change would reflect better what drug addicts actually want. Research has shown that a large majority of drug users want abstinence as a goal of their treatment (read more)

Recovery, the overriding treatment objective

Brokenshire, the UK Drugs Minister, stated that “we are looking to have greater emphasis on recovery rather than simply on treatment itself. The aim is to get people clear of addiction.”

Treatment services that are unable to get people off the addiction could risk losing government funding. This appears to be a reversal of the previous trend where recovery oriented services lost government funding while funds were directed towards harm reduction and substitution services instead.

Part of the pathway

Substitution will not be seen as a treatment aim in itself, as has been the practice. The new approach appears distinctly different. “It [substitution treatment] should be seen as part of a pathway taking people to a position where they are clear of addiction,” Brokenshire says to UK News Reporter.

The policy change is not a fare well to harm reduction as such, but to harm reduction as the overriding aim in treatment or as standalone interventions.

“A radical change”

EURAD welcomes the change. “Harm reduction while having some strengths has shown to have significant limitations and unintended negative consequences that cannot be overcome by simply amending them,” Anders Ulstein, EURAD secretary general says.

“While it is still early to tell what exactly the new policy will look like it does seem like a groundbreaking change,” Ulstein says. “I think the drug problem will still be seen predominantly as a health problem.

“What we will see is a broader recognition of what the health objectives are in drug treatment. Underlying social factors and the addiction itself will have to be seen as important as the acute symptoms of drug use”, Ulstein says.

The UK policy change will be noticed internationally since the UK for a decade has been seen as a pioneer in promoting harm reduction strategies. Its reorientation may induce other nations to reconsider their reliance on substitution and harm reduction, Ulstein thinks. “Fundamentally it will open up for a debate about the limitations of harm reduction.”

Limitations of harm reduction

“The fallacy of harm reduction was the idea that if you take a drug addict from the street, replace his/her dirty street heroin with a pharmaceutical substitute that would put the addict on track to be stabilised, to find a job, build up his/her sense of self-worth and start contributing to society, etc”, Ulstein says. “It is this particular assumption that has proven to be a miscalculation.”

“Substitution and other harm reduction services have failed to bring about a reduction of much of the associated harm that was anticipated. Indeed the numbers of overdoses and the spread of blood borne diseases have increased. The number of HIV infected injecting drug users in England and Wales is higher today than it was in 2000”.

With regard to Hepatitis C the development is equally dismal. The prevalence among IDUs has increased from 33 percent in 2000 to 42 percent in 2006. One out of five IDUs has Hepatitis B, an increase of about 200 percent since 1997 (all data from the UK Statistics Authority). Misuse of methadone is widespread. In 2006 325 drug users died from methadone poisoning alone (British Medical Journal, Sept 2008).

There are also signs that drug related crime is on the rise. The UK government (Home Office) estimates that there was 178,502 drug related criminal incidents in 2005/6, an increase of 23 per cent compared to 2004/5.

Clients in substitution programs are still suffering from lack of social integration and feeling of self worth. The prospect for many is a life long dependancy on methadone. “I think the short term rationale for substitution was relatively solid. It has contributed to the reduction in numbers of overdoses in Europe. But the consequences of large populations in lifelong substitution dependency were not well explained or debated neither with the users nor the public at large. In the early days of substitution it was presented as a limited intervention. It clearly wasn’t,” Ulstein says.

Rehabilitation ignored

One of the consequences of harm reduction dominance is that recovery oriented treatment services have been systematically neglected for years. The previous government acknowledged that only 2 percent of drug addicts now seeking help are referred to treatment and rehabilitation. The remaining 98% receives harm reduction or counseling or various community based services.

One often thinks of harm reduction as a service provided to older problem drug users that are hard to treat. In fact the summer of 2007, as many as 17.000 adolescents were registered in “community treatment” where the central component is harm reduction where they learn to minimize the harm done by their drug use and where many receive substitution.

“It seems increasing obvious that harm reduction programs have major limitations and even unintended negative consequences, in particular when they stand alone”, Ulstein says. “The way forward is to integrate them in a true continuum of care and treatment”.

Acknowledging the root causes

Finally, the UK turnaround acknowledges one vital part of the drug problem, namely that medication and hygienic measures regardless of their appropriateness, will not address the underlying root causes of drug problems and addiction.

“Harm reduction has primarily addressed acute harms while ignoring root causes,” Ulstein says. “The fact is that the majority of problem drug users have had serious problems in the past such as a broken childhood, neglect and abuse or in other ways come from disadvantageous backgrounds.”

“Obviously, methadone or a clean syringe will not adequeately address that. When the harm reduction programs become isolated from the wider recovery and addiction oriented treatment the users end up in a backwater.”

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