Commissioning, harm reduction and recovery: a conversation

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commissioning, harm reduction and recoveryThe intent of the recovery-orientated drugs policies of the UK and Scottish Governments is to allow more people to find their way to lasting recovery. After years of a harm reduction focus, it’s understandable that it might take some time to build up an expertise and experience around recovery. While there can be little doubt that higher aspirations have helped many people move on, it’s also possible that restrictive definitions and practice could be having negative consequences.

Detox Nurse, a regular contributor to this blog, suggested that commissioning may unintentionally contribute to this:

The ever-present threat of service re-tendering and a target culture, creates pressure and perverse incentives.

I blogged about ‘enforced recovery’ which generated a series of thoughtful comments, some of  which I’ve reproduced below with the permission of Mark Gilman and Detox Nurse. Mark writes in his capacity as a criminologist writing an anthropology of British addiction and not in his official role with PHE. So what is the relationship between commissioning, harm reduction and recovery?

Mark Gilman: I completely agree that enforced recovery is a complete and utter nonsense and dangerous. There are more than enough people who WANT abstinence based recovery and that is where the focus should be. We all know (well I hope we do) that you cant force recovery on anyone. By definition, they have to want it. Each of the 152 systems in Engalnd (one in each council area) should have a system that identifies people who want abstinence based recovery and directs them onto that pathway. I was in Manchester yesterday and that is starting to happen there now.

Detox Nurse: Interestingly, from drug deaths being on a downward trend since 2009 in the North West, last year DRD per 1 million went up by nearly 12.

You mention Manchester. It would be interesting to see the figures per region. I in the last couple of years Manchester and areas of Greater Manchester (Bolton, for example), re-tendered their services from NHS, to a hodgepodge of different organizations (they didn’t go for the ‘prime provider’ model). It would be interesting to see the figures from each DAAT pre and post tender. I wonder if we’d see an increase (or decrease) in DRD post service change.

Mark Gilman: I genuinely do not know if the data would show any correlation between all the retendering and redesign of services and any increase in DRDs nor whether the correlation could show any direct causative relationship. What I can say is that I live in Bury, Greater Manchester next door to Bolton and I spend a lot of time in the City of Manchester.

I have always lived here and have seen some of the impact on the ground as my real passion is anthropology and ethnography. I am writing a book at the moment and this brings me into daily contact with “addicts” and “alcoholics” across Greater Manchester. Some of these are in recovery and some are slap bang in the middle of active addition.

Some of those in active addiction are very upset by the changes in prescribing regimes as they have been able to pick up methadone (and sometimes a buprenorphine based product and sometimes injectable preparations of opioids) for years and years and years without ever having to commit to any kind of behavioural change over and above staying alive, staying out of prison and staying HIV negative.

They were never encouraged to come off benefits and take up employment in the boom years of our economy when workers from Eastern Europe and further afield came to do basic-wage unskilled labour of the kind that some may have thought presented an opportunity to our patients. Rather, they had constructed a lifetsyle that was a UK version of the USA’s “Methadone, Wine and Welfare”.

This consisted of methadone, benzos, booze, benefits and daytime TV. Of course from a pure harm reduction perspective that situation is defendable because the primary aims are to keep people alive, out of prison and HIV free. However, nothing lasts for ever, things change and the current government would not accept that situation as a success story. Moreover, many of the patients themselves wanted more than methadone, benzos, booze, benefits and daytime TV that and the UK Recovery Movement was born and continues to grow from strength to strength.

Making the decison to pursue abstinence-based recovery is a cost benefit analysis, it carries risk and everyone embarking on that journey needs to know exactly what those risks are and I would love them all to have naloxone for the journey. Would I want to encourage them not to make the journey because it is risky? No, because the fact of the matter is that doctors, dentists, lawyers and pilots set off on this risky journey when they become addicetd to opioids and a high percentage of them make it to the land of abstinence based recovery and construct lives beyond their wildest dreams there.

For all that, I simply cannot understand why anyone would want to press gang anyone aboard HMS Recovery when there are so many who want to volunteer to get on board (with Naloxone in their kit bag)

Detox Nurse: A great summary of the need to change services to promote recovery AS WELL AS harm reduction. That being said, I would argue that things aren’t as black and white as you’ve made out. Your comment suggests that in the past, harm reduction and methadone was ALL that services would offer patients. I think this does a disservice to the passionate workers of services -that you may have had a role in commissioning – who promoted recovery before recovery was so high up on the agenda.

The service I work for happens to have a significant number of workers (including in senior management) who have had an opiate dependence. All were on methadone at one point and were on the receiving end of the treatment service…and yet, they achieved recovery.

One colleague, having done a number of unsuccessful detoxes, told me that he was encouraged to take up mountain biking by his then keyworker. He never looked back. A new social network and something else to do allowed him break the cycle of addiction (excuse the pun).

Yes, methadone maintenance and HR were prioritised in the past; and yes services need to change to promote recovery more, but it’s unnuaced and simplistic to imply that recovery was never being promoted by services before government put it on the agenda.

Loved your Henley on Thames talk by the way Mark. The genie in the cider bottle story was hilarious.

Mark Gilman: You’re right to point out that things aren’t black and white, they very rarely are and its usually a case of working in the grey areas. That said, the New Labour government were heading in the recovery direction from about 2008 anyway and we would probably have been in a very similar place whatever had happened in the 2010 election.

Again you are right that here have always been good people doing good stuff but there simply werent enough good people doing enough good stuff to allow things to continue in the way they were. One of the best cases in point is Twelve Step facilitation (TSF). How many community drug services routinely and proactively promoted attendance at Narcotics Anonymous (alcohol services have tended to do better in working with AA) before there was a central government push to do so?

Despite the overwhelming evidence for the efficacy of 12 step mutual aid in assisting “addicts” and “alcoholics” (NB NOT heavy users or heavy drinkers but “addicts” and “alcoholics”) to achieve and sustain long term recovery it is STILL rare to meet people in the rooms of NA who got there via TSF from a Community Drug Service. It is getting better but there is still a long way to go.

    3 Responses to "Commissioning, harm reduction and recovery: a conversation"
    1. Detox Nurse says:

      Great post! I definitely think Mark and I are in agreement on most things. I certainly share his view that there’s more work to be done in promoting routes to recovery.

      • Mark Gilman says:

        Agreed. As i said there are some great people doing great things we just need more. At the event in Manchester last Friday it was so obvious that the “pre-THOMAS group” (an introduction to the 12 steps – I think) is doing great things. I woud have thought that they would be packed out, but they arent? It could be a system design fault or it could be a human thing such as “I’m not sending my clients there” because a) I dont like the sound of it or b) I dont understand the 12 step stuff myself and it might make me uncomfortable. On the other hand lets not be forcing abstinence based recovery on people who dont want it and are functioning just fine on Opioid Substitution Treatment (OST).

    2. Sean says:

      As a commissioner of Drug & Alcohol Services, I am disappointed looking back at Manchester over the last number of years and how tendering for service provision seems to have been more important that good service provision for the CLIENT!

      Somewhat a race to the bottom for the cheapest provider and the Value for Money criteria being that of the most importance? Also all the number of people employed in this sector who have never had any job security as subject to continued funding is on the employment contract. Things need to change; Manchester has enough clients for all service providers. Yes contracts are needed and if a service is continually underperforming, withdraw funding when another provider has been found. Luckily my colleagues and I have stayed client-focused; monies are important but so is good service provision. As you may have guessed I am no longer in the UK.

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