Changing the dynamic

Here comes a new approach to finally giving people on OST a genuine voice in their own care, says Professor Adam Winstock.

Let me start with a simple question. How many people in your service are getting the most out of their OST? You may not know. You might have a guess. But the fact that a service can’t easily answer that question is, in itself, a problem.

You can look at doses – what percentage are on methadone above 60mg, say. But that misses the point. The evidence is clear that the best outcomes come from personalised dosing. The right dose for one person is not the right dose for another. It’s not a magic number. In practice, this means that for many people being in treatment is not the same as doing well in treatment.

I’ve been prescribing opioid substitution treatment for more than 25 years. I’ve seen thousands of people cycle in and out, never quite getting stable, never quite getting the dose right, eventually concluding that treatment doesn’t work for them. The biggest single modifiable reason – not the only one, but the biggest – is that they were never on enough. People on adequate doses use less heroin, stay in treatment longer, and when they’re ready to reduce, they do it from a position of stability rather than desperation. NICE says it. The Orange guidelines say it. The evidence has said it for 40 years.

And yet here we are in 2026, with average methadone doses in England still sitting well below therapeutic thresholds, over half of people on OST classified as moderately or highly unstable by any structured measure, and no brief tool – until now – that a person could complete themselves in five minutes to make their own instability visible. With escalating deaths related to potent synthetic opioids and the need for services to adapt to the arrival of depot buprenorphine, the importance of learning how to make the most of the tools we have in treating opioid dependence is more important than ever.

That’s the gap SODA was built to fill. So what does SODA actually do? The Stability of Opioid Dose Assessor (SODA) is a seven-item questionnaire that takes about five minutes to complete. It asks about withdrawal between doses, craving, and on-top use. The score runs from zero to 20 – zero meaning treatment is doing its job, 20 meaning it really isn’t. Scores fall into four bands from stable to high instability, and the person gets immediate automated feedback in plain English.

It replaces informal, variable clinical assessment with a structured, real-time, patient-mediated process – usable by any staff member in any setting, without training, without system integration, and without adding time to existing appointments

SODA starts by asking what the person wants from treatment – whether that’s to stop using, manage active use, or reduce and eventually detox, SODA follows the patient. That’s the foundation for trust and shared decision-making.

No jargon. No medical degree needed. It can be self-administered or completed with a keyworker, nurse, peer or prescriber. No retrospective outcome monitoring. Just a structured, plain-English way for someone to articulate something they already know – that their dose isn’t covering them – in a format that makes it easier to do something about it. People can also create an anonymous account and track themselves over time, seeing how their decisions influence their treatment outcomes.

We piloted it across three community OST services in England and Wales with just over a thousand people. The results were sobering but unsurprising – 67 per cent fell into moderate or high instability bands despite being actively engaged in treatment. Being in treatment, it turns out, does not mean treatment is working.

Acceptability was high – 87 per cent rated SODA as accurate, 88 per cent found it helpful, and 72 per cent said they would definitely discuss their treatment with their prescriber after completing it. In the highest instability band, that rose to 92.6 per cent. So SODA doesn’t just measure the problem, it activates the conversation.

The majority of people in OST have far more contact with their keyworker than with their prescriber. The keyworker is the relationship. But without a structured tool, their knowledge stays informal – a hunch, a concern raised in supervision, a note in the file that might not reach the prescriber before the next review. With high staff turnover and variation in confidence around medication conversations, we’re left with informal descriptors: ‘it’s not holding her’, ‘still using on top’. 

SODA changes that dynamic. It gives non-prescribing staff a shared language and a concrete number to work with. The patient’s own score speaks for them. It turns the conversation about dose from a negotiation into a clinical discussion, and it shifts the locus of agency back towards the person in treatment where it belongs.

SODA v2 has been adapted to take into account medication adherence and will include adjustments to better accommodate long-acting injectable buprenorphine, an audio option to bypass health literacy barriers, and improved data architecture to enable population-level benchmarking for services and commissioners. Prison integration pathways are also in development – because the weeks after release from custody represent one of the highest-risk periods for opioid-related death, and continuity of care assessment matters enormously at that transition.

It’s worth being clear about what SODA is not. It’s not a medical device, it doesn’t tell people they are underdosed. It does not direct a prescription. All clinical decisions remain the responsibility of the prescriber – what SODA does is enable people to understand their treatment, their options, and how their own choices can influence their outcomes.

SODA isn’t about parking people on OST, it’s about allowing OST to fulfil its dual role as both harm reduction and a recovery tool. For people who want to come off, we’ve developed a ‘readiness to reduce’ companion – a structured assessment that starts from the position that reducing from a place of instability usually leads to escalating use and abandoned attempts. Getting stable before reducing isn’t about keeping people on treatment longer than they want to be. It’s about giving them the best possible chance when they do decide to come off.

People on OST are not passive recipients of a prescription. They know how they feel. They know when their dose is covering them, and when it isn’t. What they haven’t always had is a simple, dignified, structured way of making that knowledge count in the room where decisions get made.

SODA is that tool. It won’t replace clinical judgement, and it won’t tell a prescriber what to do. But it will make sure that what the person already knows isn’t lost in the gap between how they feel walking in and what gets discussed before they walk out.

That gap has cost lives. It’s time to close it.

SODA v1 is available at mydose.digital. The pilot evaluation has been submitted to Drug and Alcohol Review. For service partnership enquiries: adam@stayingsafer.com

Professor Adam Winstock is a consultant addiction psychiatrist, founder of the Global Drug Survey, and clinical lead for SODA