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.
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?
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)