Road to ruin

The puritanical recovery agenda is stigmatising, marginalising and endangering the health of people who use drugs or have a maintenance script, says Dr Eliot Ross Albers

For some time now the drug using community in the UK has been in a state of heightened alert and significant concern triggered by the government’s ‘recovery agenda’. This was first heralded by the launch of a document last year, bearing the logos of eight the major interior ministries including the Department of Health and Home Office, entitled Putting full recovery first – a document that has come to be known as the ‘recovery roadmap’, given that it described itself as a ‘roadmap for building a new treatment system based on recovery.’ Notable too is that the document not only insists on abstinence from substances that are causing the individual problems, but is also explicit in defining recovery as abstinence from all psychoactive substances – including substitute prescriptions.

At a recent conference I asked Duncan Selbie, the head of Public Health England, if he could provide any guarantee that those of us who are in receipt of maintenance prescriptions of opiates would not be arbitrarily forced to come off them (DDN, November 2012, page 12). In spite of insisting that drug services will ‘follow the evidence’, Selbie kept on insisting that: ‘Methadone support is a well-established contribution to recovery. What I would like to have is a broader contribution about how we can help people go beyond that… We will be concerned about rehabilitation, which isn’t the end point, being maintained on methadone.’ 

This, to say the least was not reassuring, but was entirely in keeping with a dominant theme of the government’s recent rhetoric in which ‘recovery’ has been conflated with full abstinence and in which an ‘urgent end to the current drift of far too many people into indefinite maintenance, which is a replacement of one dependency with another’ has been identified as the key objective. 

Indeed, the only indicator of success that drug treatment services will have in the new Public Health Outcomes Framework is the number of people exiting services: ‘ultimately payment will be made for full recovery only.’ They will lose these payments if people relapse and re-enter services within a given time period. In other words, the metric by which the success of future drug treatment services will be measured will be the speed with which they can get people off prescribed medications. 

Furthermore, under the new Payment by Results (PbR) system which relates to the ring-fenced treatment budget, boroughs will only receive 100 per cent of their budget if they maintain steady levels of clients exiting services over a 12 month period; failure to do so will result in a budgetary cut. These moves trivialise the complexities of drug dependence and completely overlook the frequently attendant co-morbidities. Such a financial incentive could very well lead to the exclusion of people who are neither ready for, nor seeking, abstinence. This approach furthermore minimises the importance of such proven public health measures as needle and syringe programmes (NSP), HIV treatment and testing, comprehensive hepatitis services, and overdose prevention.

Whatever one’s views on the value of the use of the term ‘recovery’ (I personally do not find it helpful, as I do not see habitual drug use as an illness to be recovered from, but rather a behaviour that people engage in), the insistence that the only satisfactory or successful outcome of an engagement with drug dependence services is abstinence is unrealistic and contrary to the well established evidence enshrined in all internationally accepted guidelines, including the UK’s own clinical guidelines. These documents all recognise that opiate maintenance programmes may need to be continued indefinitely – for as long as the individual concerned finds it helpful. You can search the literature for as long as you like, but nowhere will you find a clinically valid argument suggesting that OST only be provided for a time-limited period.

Since the release of the ‘recovery roadmap’ there has been a slew of further publications, with varying degrees of government backing, many of which have sought in various ways to disavow some of the more extreme positions taken by the former. Notable among such documents is Medications in recovery: 

re-orientating drug dependence treatment by John Strang and colleagues, which back-pedals considerably from some of the more blatantly ideological positions taken by the ‘recovery roadmap’. It disavows the notion that OST should be arbitrarily time-limited, instead insisting that services ‘ensure exits from treatment are visible to patients from the minute they walk through the door.’ 

Because of the crucial indicator embedded in PbR, as discussed above, many will be discouraged from entering into OST programmes. For many people who are experiencing problems with their drug use, knowing that they can access OST has long provided a crucial life raft of stability. This new agenda punches holes in the life raft and seems to be predicated on the notion that one has to jump, or be pushed, off of it as quickly as possible. The risks of doing so are enormous, not least of all in terms of the dangers associated with relapse, notably overdose, destabilisation, and increased vulnerability.

The consistent messaging has been that, as Duncan Selbie put it to me, ‘being maintained on methadone’ should not be seen as the end point. However, for many of us, all that we want, all that we need, is to be secure in the knowledge that our scripts will not be terminated on any grounds other than that of a mutual agreement to do so, and even then only in a carefully managed reduction schedule. Those of us who want and need nothing more from our drug services than respect, dignity and a maintenance script are being told very clearly by this government that our lives are less valid, that our choices are less legitimate, and that unless we knuckle under the cosh of a state-imposed notion of sobriety, abstinence and temperance, that we will have our benefits taken away, our children removed, our housing and employment threatened.

Selbie’s comments reiterated the moral imperative contained in the Putting full recovery first document, which, prefaced by Lord Henley, was guided by the notion that ‘our ultimate goal is to enable individuals to become free from their dependence fully and live meaningful lives.’ The notion that those of us on pharmacotherapies cannot live ‘meaningful lives’ is an insult to the many tens of thousands of us who are on long-term maintenance scripts, who are accessing harm reduction services, and are, at the same time, succeeding professionally and personally. Equally this agenda does nothing to give confidence to those who rely on them that friendly, comprehensive harm reduction services will be available and properly funded. 

The agenda is highly irresponsible in its attitude towards needle and syringe programmes, stating that ‘it is self-evident that the best protection against blood-borne viruses is full recovery.’ This statement flies in the face of the well-developed, internationally accepted evidence base that shows that the provision of comprehensive needle and syringe programmes is the most efficacious means of preventing blood-borne virus transmission among injecting drug users. Equally, the same evidence base demonstrates that for many, accessing NSPs is often the route out of illicit drug use and into pharmacotherapy programmes.

The new recovery agenda – with its marches, boat rides, right-wing Christian overtones, Russell Brands and happy-clappy ‘recovery champions’ – silences, stigmatises and further marginalises those of us who are either active drug users or are stable on maintenance scripts. It demeans our choices and denigrates our successes, and it does so on the basis of a disregard for the overwhelming body of evidence that recognises the complexity of drug dependence, and demonstrates the vital need for comprehensive harm reduction services. These services must cater for the drug-using community in all of its diversity, and not through a ‘one size fits all’ puritanical agenda. If there has ever been a time for the drug-using community to come together in defence of harm reduction, it is now.

Dr Eliot Ross Albers is executive director of the International Network of People who Use Drugs (INPUD)