Successive UK governments have been talking about ‘recovery’ from ‘addiction’ since the build up to the 2010 general election. This resulted in a target for recovery – a ‘recovery rate’ – that is defined as the number of people successfully completing treatment and not returning to treatment in the next 6 months.
The ‘successful completions’ target followed on from the two previous targets of access to treatment (measured by reductions in waiting times) and retention in treatment (measured by how many stayed in treatment for a minimum of 90 days). The first two targets could claim an evidence base. Being in treatment is a good thing as it has a protective effect and the longer you stay in treatment the better. The ‘successful completions’ target doesn’t have an evidence base and was the result of political pressure to get people out of treatment and into ‘recovery’. This pressure was particularly focused on services providing Opioid Substitution Treatment (OST) to people who came into treatment dependent (‘addicted’) to heroin. There are problems with using successful completions of treatment as a proxy measure of recovery. We are asked to accept that leaving treatment means entering recovery and that not returning to treatment in six months means that the person has stayed in recovery. But, how would we know what has happened to people leaving treatment?
This is where the need for a peer led recovery community in every local authority becomes crucial. People with a Substance Use Disorder (SUD) – the preferred term for ‘addiction’, ‘alcoholism’, ‘substance misuse’ or ‘dependence’ – experience this in isolation. One of the key features of living with a SUD is being alone. Conversely, one of the key features of successful recovery from a SUD is community and active engagement with positive social networks. If we could ensure that everyone leaving treatment is connected to a recovery community then we could claim that the ‘successful completions’ target is linked to an evidence base.
There are some good examples of places where this is working well (eg Lancashire, Birmingham, Manchester, Calderdale, Cumbria) and the commissioners recognise the importance of establishing and supporting a recovery community in their local authority area. This is even more important as budgets shrink and contracts are let with as much as 50% less financial resource.
One of the ways of ensuring this is for commissioners to write the requirement into specifications when tendering services and issuing invitations to tender. Bidding organisations could then be asked to evidence how they have achieved this in other areas where they are already operating. Or, they could be asked to detail exactly how they would operate to ensure that they build a recovery community in the area over the time of the contract being let. One of the key markers for this would be the number of new independent and peer led mutual aid groups that are established over the time of the contract.
There are many service provider organisations that talk about recovery and recovery communities but on inspection these tend to be groups of their own service users and not independent peer led organisations such as Lancashire User Forum and Red Rose Recovery, The Well in Cumbria and The Basement Recovery Projects in Calderdale and Kirklees. There are also some ‘patients’ in treatment that only want a medical and clinical OST service on a maintenance basis. Offering access to the recovery community and exposing these patients to peers who were once like them is as much as might be possible until they feel motivated to change. There is no point in trying to push people out of treatment if they are settled on OST especially when they are in employment, have a home and family and friends. There are more than enough people in treatment who do want to leave and join a recovery community.
The key to this lies in some kind of ‘patient segmentation’. In any population of people in treatment, there will be a group who are not interested in recovery because they are settled on OST. There will be another group who are definitely ready for recovery and a group who are not sure. The quickest wins will come from concentrating on the group who are keen and ready to move. They can be directed onto a discrete community detoxification pathway that utilises specific detoxification medications such as the Lofexedine and Buprenorphine combination as described in Detox In A Box (https://drinkanddrugsnews.com/wp-content/uploads/2016/07/DDN-0716-web.pdf page 22). Where services are combined drugs and alcohol then the other place to start is with people whose primary problem relates to alcohol. They, almost by definition, will be looking to pursue abstinence based recovery for simple health reasons. One place to bring these two groups (the opioid detoxification people and the alcohol abstainers) together would be in ACT Peer Recovery mutual aid meetings. ACT Peer Recovery is a form of mutual aid that focuses purely on behaviour change and offers an easy way into mutual aid and recovery communities. Once people have experienced positive behaviour change they tend to want more and see the importance of changing other behaviours that have been stalling their progress in recovery. ACT Peer Recovery works perfectly alongside the 12 step mutual aid fellowships of AA, NA and CA.
Once we have established a thriving local recovery community we should be able to monitor the progress of those who have successfully completed treatment. Experience in those areas where this is happening illustrates the importance of the early identification of relapse. If someone relapses and stops attending their mutual aid meetings or disconnects from the recovery community we will know and be able to reach out and assertively support the person back into treatment and recovery. Commissioned treatment providers working in complete partnership with thriving local recovery communities are the yin and yang of a complete treatment and recovery system. This is the way to deal with reductions in funding and to provide the necessary evidence that is required to legitimate successful completions of treatment as a recovery rate.