It’s time to move clear of the abstinence v prescribing debate and agree on a holistic, pragmatic approach, says Oscar D’Agnone.
How best to treat people with drug addiction? Nothing has been more contentious and encouraged more passion than the divide between the proponents of the abstinence approach and the defenders of substitute prescribing. As with every controversial debate, each camp has its pros and cons. Those who promote abstinence argue that ‘parking people on methadone indefinitely’ does not provide a solution as it is substituting one drug with another drug without solving the issue of addiction itself. On the other hand, those who recommend substitute prescribing highlight the extremely high rate of relapses among addicts that undergo full abstinence and the very dangerous consequences of such relapses.
What has seemed to be a never-ending discussion within the sector might actually come to an end with the NTA’s most recent report on prescribing substitute medication. The report recognises that both sides have valid points and that the division between the ‘abstinence’ and ‘prescribing’ approaches is a false dichotomy. Indeed, drug treatment services do not have to choose to favour one approach over the other but should move towards a holistic approach that uses a wide range of interventions that are considered best for the individual. When treating addictions, you cannot apply the same ‘medicine’ to every patient. Having come across thousands of individuals through my work at the national health and social care charity, CRI, I have come to realise that there are so many complex social and medical factors involved in each person’s addiction, that every situation is intrinsically different.
On 5 September CRI and the University of Manchester will run a conference where leading clinicians specialising in drug misuse treatment will be looking at the ways to ensure the sector moves away from the dogmas of the past and develops a holistic approach, integrating medical, psychological and social interventions, where each case will be treated according to the individual needs.
Such a holistic approach must be based on a real partnership between individuals and the clinicians involved in their care. It is the doctors’ responsibility not to apply a blanket rule for all those seeking treatment but to tailor treatment options to their patients’ specific needs. It is also vital that individuals provide their informed consent by being made aware of the benefits and risks involved in different treatment options.
For some individuals, seeking abstinence can be the most effective way of overcoming their problem, but for many others this could lead to serious consequences and an approach focusing on harm reduction will be more suitable. Indeed, individuals who are not quite ready to be abstinent would benefit from being prescribed a substitute medication for as long as they need in order to enable them to join structured recovery programmes including psychosocial interventions, involving family members and friends, addressing housing and educational needs and looking into other physical and mental health problems. Methadone should not be an end in itself but a means to eventually become totally free from drug dependence when ready.
Once doctors and patients have agreed on a treatment option, it is important that individuals take ownership of their recovery programme. This should be reviewed and adapted on a regular basis and progress evaluation should not only look at clinical information but should also take into account quality of life factors. Doctors should ensure individuals are involved in decision making on issues such as appropriate medications, doses and regimes. They should also work jointly with patients to ensure they can come off opiate substitute medications at a rate that is safe and they feel comfortable with.
Beyond clinical support, it is vital that people starting drug treatment programmes are able to see exits from it at some point, for instance by developing links with a recovery community or by having the opportunity to become peer mentors or coaches once they have stopped using drugs.
We feel it is important that a holistic approach includes psychological help and support to address other aspects of their lives which are intrinsically linked to their drug use. Whether it involves helping them to get a job or find suitable housing, it is vital that we address all these complex social issues to ensure drug users are able to get their lives back on track.
It is time for us as a community to end this division and come together to endorse a more holistic, pragmatic approach focusing on individual needs, where the service user (not the drug) is at the centre. Only then, will we be able to support drug users effectively and will society reap the benefits of improving public health.
The Recovery and beyond conference – clinical research and practice for building the holistic recovery model and policy of the future is being held by CRI and the University of Manchester at the Midland Hotel in Manchester on 5 September. For more information please visit www.cri.org.uk/clinical.
Dr Oscar D’Agnone is CRI’s clinical director