Drug “recovery” versus “maintenance” and the smart use of indicators

  

There is a consultation on new guidance for substance misuse. 

Drug Misuse and Dependence: UK Guidelines on Clinical Management, Consultation on updated draft 2016
 

There’s a specific comment re recovery vs maintenance:-

 

A fully positive approach for those who choose a maintenance oriented recovery path’ – ‘Positive feedback should be provided both for individuals who are successfully engaged in OST and those engaging in abstinence based treatment…

these discussions should not be driven by a pre existing preferred orientation of the clinician or service but should be a professional one, reliant on the clinician providing the best advice they can and enabling the patient to make their own, informed, choices, underpinned with information about the risks, benefits and known outcomes of the options. It is inappropriate, in providing ethical evidenced based treatment, for services to create a sense that those opting for a maintenance based treatment are making a poorer choice…”

 

This seems very patient oriented to me.

 

I do have an ongoing concern about the way in which the indicators are used.

I worry here about the use of the Public Health Outcome Framework (PHOF) and they way these are operationalised in practice. There seems an approach of using the indicators in to make exiting treatment the only outcome with a value.

I know Sheffield is constantly criticised for its lower levels of proportions of treatment population exiting and staying out etc.
Recovery is a good thing, nobody disputes this. however, there are no indicators nationally that reward quality of treatment or within treatment progress etc.  

Some history is important.

when the 2010 drug strategy was published, commissioners and providers had to about turn decades of getting people into treatment and providing maintenance therapy. 

Up till this point, success in drug services was classed as a high proportion of those in treatment being ‘retained’. 

2010 happened, the drug strategy was published and all of a sudden recovery was all. 

 The PHOF was put in place after the 2010 drug strategy which was all ‘about turn, time to get everyone out’ after trying to undo decades of “keep them in and stop them causing a problem” model of treatment.

 

Why this matters

A relentless and singular approach towards recovery is ALL that matters doesn’t reflect reality, and may be harmful.

 

All services can cite lots of stories of chaotic, needle sharing, regular offending, Hep or HIV positive homeless person who starts off just engaging with NEX to get clean works. Often later, usually with timing that reflects the needs of those users, they later comes into treatment, are stabilised on methadone, has their wrap around needs met, engaged in appointments, gets housing sorted, benefits, into treatment for their physical health issues, stops injecting or use on top, and is maintained for a long period, no longer offending, not spreading infection via shared use, has some structure and commitments that they can stick to.

 

This is not ‘recovery’ as is defined by the 2010 strategy, but for this group their life quality, and their detrimental impact on services is sooo much better but that doesn’t exist as we a) haven’t exited them and b) they will likely have been in treatment for over 6 years etc.

 

Had we only focused on ‘recovery’ as is defined in the strategy this group of people would be “treatment failures” and abandoned, with all the consequent downstream consequences.

 

 

Methadone warehouses and the PHOF target

I’ve heard many stories that services are ‘warehousing patients on methadone’. Whilst this is maybe one conclusion that might be drawn from critical look at the data, the reality is more complex. Also often the data doesn’t reflect what’s really going on in a system. All datasets are full of holes and imperfections, the drug service data is no exception.

 

The key PHOF indicator is our main stick we’re beaten with when all it means is we exited someone successfully and they haven’t come back into treatment within 6 months. 

This is important: a) doesn’t mean they aren’t using drugs again, b) gives agencies an incentive to turn at risk people away (we don’t – and wouldn’t), and c) bizarrely seems to suggest everyone is fine to relapse and come back into treatment after 7 + months. At (very) best it is a highly imperfect target and there is no measure of meaningful progress within treatment.

 

To me the real issue with the direction of phe and the PHOF we are measured on is how narrow it is – as long as we don’t see people again within 6 months it’s all fine data wise. Doesn’t feel good enough… 

 

 

 

So, in summary

Sure recovery is important. Were it my kids that’s what I’d want. A focus on recovery sets the default expectation, may set the dial and focuses the mind.

However it might not be appropriate for all so some flexibility is needed and given the not insignificant imperfections of the indicators some careful conversations are needed about how to manage systems.

The national clinical guidance is important. It may be more important than imperfect and improper performance management using a poor indicator.

The real issue is how can we make these two compatible. 

It seems an appropriate ambition for everyone is recovery but recovery doesn’t always look like abstinence for some people it means stopping illicit use and chaos and living a meaningful existence on maintenance medication. Accepting this may be a deeply unpopular view in many circles it is also a pragmatic one. 

What may be missing is an indicator that reflects the completist of users lives, the decisions they themselves make about entering and existing treatment and recovery. This may indeed be an indicator free zone. Till we sort this, there is a scenario that all that matters is treatment exit as a – poor? – proxy for recovery.

The key issue then is a precise definition of the terms “recovery”, that may vary from person to person, and only the person in treatment should decide what is best for them.

 Don’t get me wrong, I’m not having a go at PHOF per se here, it’s a good thing. I am concerned about the smart use of indicators and data and the inappropriate use of indicators that don’t reflect the complexity of people’s lives.

 

 

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