Talking therapies are among the many options that should be offered alongside OST, says Clive Hallam.
Recently, a post on social media considered the question of whether talking therapies added any value to people who were committed to opioid substitution treatment (OST) on a long-term basis.
National data shows the group of long-term, committed recipients of OST is growing, month on month, across the country. However it isn’t clear whether this is because of a personal desire for, and commitment to, long-term OST, or because people have been stranded on repeat prescriptions, with minimal contact from a practitioner – both conditions exist.
Certainly, the figures correspond with cohorts of individuals who have long careers of substance use and are highly complex, and this brings into question the ability of current treatment delivery to respond appropriately.
People may commit to long-term, or lifetime, treatment for a variety of reasons, objective and subjective. There may be a clear clinical need in certain cases; however, people also resist change and avoid challenge.
Pharmacological interventions are comparatively well researched and evidenced, with the effects quite easy to predict and observe. Therapeutic doses can also be achieved relatively quickly, enabling an individual’s physical circumstances to be moderated effectively. But the effect of those doses may be more than we envisaged in terms of affecting someone’s ability to interact, and some researchers have linked methadone with significant cognitive impairment.
By comparison, talking therapies depend almost exclusively on the specific relationship between the person and the practitioner to be effective – the emotional context and connection, and a desire to respond or change dynamically.
NICE considers that few talking therapies have the evidence base to warrant their use, particularly in this client group, preferring contingency management to support people in OST. But if a person’s ability to reason is adversely affected by opiate use, might this be the primary reason for the failure of talking therapies – and should this be factored into decisions about treatment?
Other issues also come into play here. At what point has the impact on the individual been measured? How resistant is the person to talking? Do they regularly miss appointments believing they won’t benefit from them? Do they present on the autistic spectrum? Can they get their prescription and side-step psychosocial altogether? All these questions are as relevant for the long-term methadone patient as for the person just starting treatment, and make the success of talking therapies difficult to qualify.
What could be of more importance is a person’s access to meaningful use of time, whether to pursue hobbies, learning, look for volunteering or work opportunities, or otherwise be diverted from their established courses of action and interaction. There is a clear role here for mutual aid, residential rehabilitation and therapeutic communities – yet aren’t these types of talking therapies?
Nicholas Christakis (Connected, Harper Press, 2009) speaks of changing people’s outlooks and cultural position. He argues that individuals in a concentrated network naturally exhibit its predominant emotions, actions and cultural perspectives. To effect positive and sustainable change, exposure to ‘integrated’ networks, with a range of views and cultural stances is necessary. Mutual aid and recovery communities are excellent gateways to such networks; concepts such as time-banking and co-production enable individuals to explore their aspirations, skills and knowledge. This is supported by the observations of William L White in the United States.
Experience across the country has demonstrated the value of running such programmes side by side, enthusing people to be involved in activities such as equine therapy, working in the countryside, and time-banking with local communities, at the same time as receiving OST.
Fundamental to this approach has been psychosocial support, providing an opportunity to discuss issues, events and concerns in an encouraging, supporting and enabling environment. Keyworkers and psychosocial practitioners can have a crucial role to play in enabling individuals to experience and understand their worth in such environments.
Any viable system must offer a range of interventions that present the most options for pursuing a full life. If this isn’t also given to lifetime methadone patients, including the option to stop OST, how can they make an informed judgement?
During my career as a commissioner, I’ve resisted the concept of tendering every few years to find the ‘best response’, the ‘most economically advantageous tender’ and the ‘best provider’ for the task. Treatment provision is fundamentally different to purchasing stationery and, while there’s a place for market testing, it can be detrimental to long-term care and outcomes that celebrate the best in individuals.
Commissioning is an art form, working with people in treatment, families and communities, providers and partners to ensure maximum opportunities are identified, explored and delivered. It is about seeking solutions that are sometimes the best, sometimes wrong, often pragmatic, but always looking to offer individuals the chance to choose something that is right for them. That may be a lifetime prescription – equally, it may be a detox through a personal realisation after years that there’s something more to life. We shouldn’t define either aspiration, or delivery, by saying one way or another is the only way.
The best treatment system provides a spectrum of interventions for those wishing to explore them. While we live in a time of ‘austerity’ there has to be sufficient funding in the system to adequately care for people through prevention, harm reduction, early intervention, structured community and residential interventions and aftercare – and, underlying it all, mutual aid and positive social networking. The question should be, how do we employ all interventions in a way that enables individuals to achieve their highest potential, benefiting themselves and those around them. There isn’t one size that fits all.
Our current system of drug treatment, begun under the tenets of harm reduction, remains predicated on the criminal justice arguments of the early 2000s, which unfortunately hides the more relevant harm reduction message. People do not need to be placed on methadone for life and until this argument changes, options for recovery will remain limited, with interventions responding in part only to the needs of the individual.
The narrow argument concerning what is right for individuals needs to be consigned to history. Individuals, commissioners and providers must move to one that liberates individuals to make the decisions that are right for them – governed by facts, aided by considered support, and revelling in aspiration and recovery. There are many routes to recovery; as many as there are people who need them.
Clive Hallam has worked in the sector for 13 years as a commissioner and consultant