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Enforced ‘recovery’ unethical

Posted · 16 Comments

England-&-Scotland

Wales and Scotland and have national naloxone programmes, England does not. In light of the jump in drugs deaths related to opioids, concerns have been raised again about the situation. John Jolly, CEO of Blenheim, writes powerfully on his blog about the shame of this and points the finger at disinvestment in harm reduction and drug services.

He praises the situation in Scotland:

Scotland has allowed naloxone to be provided to services without prescription, for use in an emergency. This enables Scottish drug treatment and homeless hostel staff to have naloxone ready for use. We urgently need the law in the UK changed to allow this.

Something else caught my attention here though:

Many people I suspect are now being encouraged to leave treatment before they are ready.

This echoes comments made on my blog recently by Detox Nurse, a regular commenter on Recovery Review. Considering the rise in deaths, Detox Nurse writes:

I wonder if this is a reflection of a change in service provision and how services are implementing the transition from harm reduction to recovery, particularly in relation to ORT prescribing.

An example of concerning practice is given:

I shadowed a doctor in another service last year. I recall one particular client he saw, a lady who had recently been started on 20mg methadone. She’d been providing 6AM positive urine samples and was in tears, requesting the doctor increase her prescription to 30mg. He said he wouldn’t increase her methadone until she gave some negative urine samples. I felt uncomfortable as I thought this were the wrong way round. She wanted an increase in methadone to help to stop using heroin – if she’d been able to stop using on 20mg, then she wouldn’t have been asking for an increase. I often wonder what happened to her.

But drug deaths are down in Scotland which also has a recovery-oriented drugs policy. (I’m aware we need to be careful when comparing individual years and countries.) Detox Nurse responds:

Yes, that’s a good point, though I wonder if there’s a possibility that Scotland still favors a harm reduction approach over a recovery treatment system? I guess what I’m saying is, is it easier to get on a script in Scotland than in England/Wales?

I don’t know the answer to that, but I do know I’ve never come across the sort of practice where a patient is punished for using on top of the script during a titration onto methadone – not being able to stop using is the very reason they are asking for help. If everything is as it seemed, what on earth is going on? Detox Nurse gives a view:

With regards to the doctor I shadowed, I think this was his consultant’s interpretation of how methadone should be prescribed within a recovery service. From speaking to other workers within that organisation, this wasn’t an isolated incident (time limited prescriptions was another issue).

I do find this to be of concern. Is it possible that a recovery orientation is being interpreted as externally imposed abstinence? Clearly that would be dangerous and ethically quite wrong.

It is possible to have harm reduction embedded in the heart of recovery-oriented services. In fact, an ideal situation would be that we stop thinking that the two are separate. They should be joined at the hip, though there are tensions to be explored and resolved.

Naloxone is a part of the armory that we can use to tackle drug-related deaths. So is equitable and timely access to opioid replacement therapy. Although we still have an evidence gap I suspect that equitable and timely access to recovery communities will also be shown to be protective, as will access to high quality abstinence oriented treatment of adequate duration and with good aftercare provision. The other side of the coin, and this is for another blog perhaps, is that there are also reports (often from people in recovery) of having attempts to move on thwarted by treatment professionals.

For the moment, if poor practice is happening under the flag of recovery, it needs to be called out and halted. We have national clinical guidelines for a reason and as they are revised over the next year or so, perhaps some of the tensions inherent can be teased out.

In the meantime, I support calls for a national naloxone programme for England – why not have recovering people help deliver training? This already happens in some services. We need a full range of options from coal-face injecting equipment provision through to residential rehab. These services need to be joined up, with good clinical governance across the range, to ensure that scenarios like the one described above do not happen.

[Update: Northern Ireland also has a Naloxone programme. A regional protocol and Patient Group Direction were produced in order to deliver an effective programme. Thanks to Trudi Coyne for the information]

    16 Responses to "Enforced ‘recovery’ unethical"
    1. Detox Nurse says:

      My goodness, I really should read – and re-read – my comments before I hit the post button. Perhaps I need a sub-editor. My grammar is awful!

      Many thanks for this considered post. I know some of my comments can look as though I have negative view of the shift from harm reduction to a recovery treatment system. My concern is simply that we risking throwing the baby out with the bath water.

      With regards to this particular post, I suspect that the current climate around the commissioning of addiction services is in part responsible for the examples I provided. The ever threat of service re-tendering and a target culture, creates pressure and perverse incentives.

      It’s funny, as before (my time) government incentivised getting individuals into treatment…and keeping them there. Now, it’s more like “get ’em out, and keep ’em out”. We can’t deny the financial imperative behind this paradigm shift.

      I’m very fortunate to work for a service whose doctors have held their nerve and have not reacted rashly to the pressure of hitting targets. Admittedly this may have negative consequences come re-tender time.

    2. The English laws are a load of shit! They should be called Russians, as they have stopped Methadone and within the 1st year they had a hepatitis epidemic !! Over 1 million people got this illness whether acute or chronic. The point I’m making is that the English are aswell stopping all their treatments as they don’t agree with “Naloxone ” . They are trying to save money, especially after building Wembley and London eyes etc…. They need to stop the deaths rising through opiates, that 0.4 dose can save their lives and I find that the English show that they don’t care about people in Recovery or at Risk of Viruses. “Total joke” .Davie( (Ha Ha).

    3. Mark Gilman says:

      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 direct them onto that pathway. I was in Manchester yesterday and that is starting to happen there now

      • djmac says:

        There are more than enough people who WANT abstinence based recovery and that is where the focus should be.

        Absolutely!

      • Detox Nurse says:

        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.

        http://www.ons.gov.uk/ons/rel/subnational-health3/deaths-related-to-drug-poisoning/england-and-wales—2013/stb—deaths-related-to-drug-poisoning-in-england-and-wales–2013.html#tab-Geographical-Variations-in-Deaths-Related-to-Drug-Misuse

        • Mark Gilman says:

          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 says:

            Hi Mark – 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 says:

              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.

    4. Jock says:

      Perhaps the doctor refused to raise her dose because he was concerned about her risk of overdose – not because he was callous or punishing or incompetent or driven by some ideological agenda to enforce recovery. Perhaps he was acting out of compassionate clinical judgement trying to avoid a tragedy. I don’t know the details of this case but as I understand induction onto methadone is a dangerous time for overdose and when someone is struggling to stop using heroin as they start on the program surely it is prudent and ethical to minimise the risk of death at the expence of causing a patient discomfort however dustressing that may be.

      • Detox Nurse says:

        That’s a possibility, but if all doctors where paralysed by a fear of increasing ORT when someone gives a positive urine sample, then hardly any patients would ever get above 20mg.

    5. Anon says:

      Re – naloxone in England, I understand that the fact that it is not yet available is because they are waiting for the better clinical evidence of effectiveness from a large trial (which will report shortly). Currently the evidence is considered inadequate. I laud the Scottish and NI decision to provide it on a precuationary basis, but in fairness I don’t think that NHS England have rejected Naloxone, they just follow a more rigid and timid understanding of evidence based care.

      • Hi Anon,
        I wonder if you are talking about the n-Alive trial? But surely that trial is only designed to see whether giving naloxone to people who leave prison will reduce the very high death rate which is seen in the first four weeks after leaving prison. The planned trial is as you say, very large, and only started its pilot stage last year. I understand it would take several years before the full results came out.

        Meanwhile, within the Scottish model everyone who leaves a Scottish prison now has access to training and a naloxone kit as they leave the gates. I understand that if this shows a statistically significant reduction in DRDs for people leaving prison, it is possible the full n-Alive trial may no longer be needed as we would have the answer for the prison population.

        However this trial is not asking about the efficacy of take-home-naloxone provision for the wider population of people who use drugs (not everybody is in prison fortunately) . The ACMD stated in 2012 that the case for prescribing take-home kits to opiate users has now been made, and not only for people who use drugs to carry kits, but also they suggested for the wider community around them (parents, partners, hostel workers, outreach workers) to carry them.

        Following the ACMD request, and their own consultation, the MHRA have now apparently (in July) now agreed to this wider provision, which will come into force from 1/10/15 (or from 1/4/15 if we can persuade them to hurry it through their admin) .

        It is a mystery to me why any English service which prescribes methadone and buprenorphine would not now also prescribe at least one take-home-naloxone kit to each person. They cost £18 and keep for three years. Experience shows that they will not usually be used to revive the person to whom they are prescribed, but more likely be used by them or indeed by somebody else, to revive a third person. Therefore they should not just be prescribed to those thought more at risk (impossible to judge who that might be anyway) but rather the aim is to get a high percentage of OD training and kits out into the drug using community at large, then lives will be saved. Naloxone kits are much cheaper than epipens, which are renewed each year. Are people who eat peanuts worth more than people who use drugs I wonder? Surely not.

        And now we see that the English heroin and morphine associated deaths rose by 32% during 2013, when the Welsh DRDs deaths are static and the Scottish are even down slightly over the same period. The WHO guidance is in its final draft and I am told will say:

        (verbal communication February 2014) :
        “People likely to witness opiate overdose should have access to naloxone and be instructed in its administration to enable them to use it for the emergency management of opiate overdose”

        I personally believe that English prescribers should now immediately follow their Scottish and Welsh compatriots and prescribe a naloxone kit for everybody who is in drug treatment (and as soon as the new regulations come into force, to those in the community who may also be first responders as well).

        We don’t need an expensive “national programme” when the evidence is already in, and the kit is licensed for use. Just do it.

    6. Ash says:

      I’ve no doubt the doctor is compassionate but as detox nurse says ‘paralysed by fear’ this is apparent in some services. I call it the doctors’ ‘White knuckle ride’.

      I’m a firm believer, if there’s client capacity, in the client taking responsibility for their welfare and making educated decisions regarding their treatment themselves; as long the prescribing doctor and key-workers explain the risks (overdose prevention info), and increases are done appropriately and in conjunction with the key-working sessions. These sessions will focus on managing triggers & craving, Seemingly irrelevant decision & high risk situations, and withdrawal symptoms etc.

      My feelings are titration is too slow due to risk aversion which leads to clients getting trapped in a double habit of methadone and heroin by default.

      Although I am now a service manager, I am also ex service user, so speak from both side of the coin. Many of my colleagues who also have personal experience of ORT, also regularly express their frustrations regarding the risk aversion shown by our prescribing nurses and doctors, and there is a feeling that punitive measures are often threatened or used when a client hasn’t been able to provide a negative sample or they’ve been difficult due their frustrations in receiving too low a dose.

      I know the Orange ORT guidelines are only guidelines and an experienced doctor can work outside them if they are able to justify their decisions, so I wish some doctors would.

      Grammar is also not my strong point

    7. martin says:

      The issues are twofold, one with commissioning targets and the other with misinterpretation of recovery. Three examples of poor recovery commissioning targets are

      1. To offer Hep C tests, as a result providers have litrally been doing just that and not actually testing on the scale that they should have been, it would be interesting to note how many of the new DRDs stats also had active Hep C.

      2. Some commissioners have a target of between 50%-75% cessation of IV use at the six month review (hard to belive but true).

      3. Finally the target of 20 0r 30 etc clients being exited drug free every month. This is a small example but factor in the unintended consequences of reaching these targets and you begin to appreciate the potential harm.

      Too often recovery is seen through the eye of a prescription and the workforce are more like prescribing managers with little attention paid to the acrual of recovery capital. One of the key policies/guidance is Medications in Recovery by John Strang and I have allways wondered why the sector have never embraced this on a wider scale. His work talks about auditing the balance and segmenting the populations in order to offer a range of interventions so that at every point in a treatment journey they can be offerred in a way that is appropriate to an individuals stage of recovery.

      A one size fits all approach will never work, a young mother with children will need something totally different to a 45yr old male with liver disease. However to truely implement the Strang report means addressing issues within the sector which we currently choose to ignore. The sector and populations are changing and we need to be adopting different approaches, what do we do with end of life clients?? We have new challenges looming and we must be prepared.

      Historically we have been poor at enabling and supporting clients to achieve abstinence but thankfully this has changed over the last 5 years. A big positive change as occurred in the name of recovery but lets not forget, ‘the apples that fall from the fruit tree that sits in drug treatment fall far and wide’.

    8. Jason wallace says:

      Firstly let me say an investment of less than 2p a day could say a life (naloxone) surely the most important outcome any commissioner/provider could wish for would be to keep your clients alive long enough to find recovery.

      Next there is no dispute that methadone/suboxone is a effective ORT how it is prescribed is a different matter when it comes to withholding ORT google this report from UN clearly states withholding ORT is paramount to torture and abuse.
      Now have a look at the report details below pages 16 & 17 are of particular interest:

      “Report of the Special Rapporteur on torture and other cruel, inhuman or degrading treatment or punishment, Juan E. Méndez ” 1st February 2013 was published not that long ago.

      The evidence for ORT as a protective factor in Overdose is overwhelming so is the Global evidence that naloxone prevents fatal overdoses I truly fair to see where the problem lies for UK Gov.

      I would advocate that there is a strong argument as a duty of care that we retain people in treatment better and give everyone with a history of using opiates in the UK a supply of Naloxone it’s a no brainier

      • djmac says:

        On Naloxone, it’s pretty clear that it ought to be dispensed as a matter of course to those at risk. Access to ORT and a range of other treatment options should be available across the UK (and wider) and nobody should have an enforced reduction. But not every service user wants to be on ORT for ever, so the questions that come up for me are –

        When is it right to move on?
        What sort of interventions are associated with abstinent recovery?
        How do we ensure harm reduction is also at the heart of those interventions?
        How can the process be kept as safe as possible?
        How can we ensure early re-entry if relapse occurs?
        How do we raise aspiration in the system?

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