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Is abstinence a political or personal goal?

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Abstinence a political goal?

Abstinence political?

In a commentary, Drug and Alcohol Findings (DAF) tackles the contentious issue of what addiction treatment is trying to achieve – the ‘what should treatment be for?’ question. The ‘A’ word (abstinence) comes up of course – incredibly it’s still seen as contentious that a significant proportion of clients/patients might want abstinent recovery. The development of recovery-oriented policy in the UK government has been framed recently as largely political, instead of as something a significant proportion of service users and their families want.

There are legitimate questions to be answered here, especially if treatment is to be resourced from the public purse. Drug and Alcohol findings (DAF) details the challenge:

Inevitably that ‘should’ word plunges us in to the worlds of value and politics not susceptible to resolution via randomised controlled trial.

Lessons

Then there is the fact that what we look to in order to inform us – research – is not neutral either. Two lessons need to be learned says the commentator:

How those worlds sometimes very directly generate research in the expectation that the results will help further those agendas; and how those worlds influence the research itself, which like every other intentional human action, is a motivated endeavour; science is never just about science.

I guess the same is true for commentators and bloggers. DAF points out that the UKDPC recovery definition does not mention abstinence. (Though it seems prudent to mention that of six prominent definitions laid out in a recent paper, four actually do).

The commentary sets out the view that treatment populations are made up of folk with multiple problems who are destined to relapse unless comprehensive approaches to social dislocation are embraced. This will, in turn, limit the numbers that can be treated due to resource limitations. There are dangers inherent in alternatives:

Must we set our sights lower, and ameliorate while we seek usually only slightly to accelerate the normal processes of remission – or is that what could prove a self-fulfilling lack of ambition?

DORIS Drubbed

Sadly the largest drug treatment outcome study ever done in Scotland, DORIS, gets a drubbing here, or at least the way it was interpreted does. In fact this section brought memories for me of The New Abstentionists for its tone and content. The finding that patients want abstinence is critically examined and found wanting. The headlining of DORIS is described as ‘sloppy at best and misleading at worst’, the end result is highlighted as a possible example of ‘a case of science being bent to political agendas’. I think this is a very harsh framing and risks flushing the baby, bathwater and all into a very deep and unsanitary toilet.

Where does this leave us? You could be forgiven for coming out of this thinking that no research can be trusted, that all research is political, particularly recovery-oriented research, and that despite what patients appear to say – “I want to achieve abstinent recovery” – what they actually mean is something quite different.

Not so fast, for after this pounding the commentary concludes with an olive branch, or at the very least, a concession:

However the individual defines it, stopping use of some drugs (especially use so problematic that it has driven them to seek help) is a common goal, and that for substitute prescribing patients, it often extends to eventually being free of legal substitutes too.

Meanwhile, back in the real world

There is evidence that a significant proportion of clients want abstinence. At the coal face, setting the goal of abstinence from all drugs, illicit and prescribed, is fairly common, not a rarity. Granted, timescales set to achieve this vary. Some clients will be ambivalent. Others will be sure. Sadly, there is also evidence of a mismatch between what professionals think their clients want and can achieve and what those clients actually want and can achieve. Families are much clearer on this; it’s not hard when you think of what you’d want for your partner, your parent, your child.

David Best asks a legitimate related question:

So this question about community recovery capital is partly about stigma and discrimination – whether professionals (in the addictions and related field) believe that people recover and act accordingly. If you are in a system where all the addiction money is spent on substitution therapies, on detox and on counselling, your system does not believe that people recover!

We need a treatment system with options, that is joined up, that doesn’t frame abstinence as unachievable, politically motivated or out of step with the evidence. We need treatment services where there is evidence of recovery, where recovering people are visible and where staff have fluency in the language and practice of recovery.

There are places where this is beginning to happen and where it is happening this is not directly because of politics or the evidence base or because of science and dusty papers published by special groups. No, much of it is because of recovering people, staff with aspiration and commissioners with vision. It could be much better very quickly, as Prof Best says, if all professionals believed that people do recover and acted accordingly.

(This article was changed on 10th July 2014 to reflect clarification from Drug and Alcohol Findings)

    5 Responses to "Is abstinence a political or personal goal?"
    1. Violeta Ainslie says:

      Over the 25 years that I have worked in the substance misuse sector I have read many, many, many papers about what works and what doesn’t work and what might work in relation to the treatment of problematic substance use. Only once in all that time did I read a paper that bothered to look at the 50% or so of people who successfully address their issues with substances and never go anywhere near a treatment service.

      • djmac says:

        There are plenty of papers on ‘natural recovery’ though it is hard to study and not nearly so well researched as treatment populations are. William White references some of those papers in his roundup of 415 studies on remission/recovery.

    2. Mike Ashton says:

      Thanks djmac for bringing our efforts to wider attention. One thing I should correct. We did not describe the DORIS study as ‘sloppy at best and misleading at worst’ or a ‘possible example of ‘a case of science being bent to political agendas’. We were talking about the use the DORIS findings were put to and how they were reported.

      But about DORIS, it does remain a mystery why the abstinence rate after methadone was based on people who started that treatment only after another one (not the way it was done in other such studies) and why the comparison with NTORS in England failed to mention that or that the English study permitted cannabis use in its definition of abstinence. Both invalidate the comparison made in a DORIS report.1

      1 McKeganey N. et al. Abstinence and drug abuse treatment: results from the Drug Outcome Research in Scotland study. Drugs: Education, Prevention & Policy: 2006, 13(6), p. 537–550.

      • djmac says:

        Thanks for your response. I’ve re-read the piece and have to say I thought the ‘all this’ meant everything preceding, not just the way DORIS was headlined, but I’ll change the text to reflect your clarification. I agree that it’s difficult to make comparisons between these two studies for various reasons, but particularly for the different definitions of abstinence.

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