Heroin Harm Reduction: Naloxone based reflections

Posted on 3 CommentsPosted in Harm Reduction, History, Treatment, Uncategorised










In 1987 the south of England was hit by one of the worst storms in history when hurricane force winds ripped up trees and tore off roofs. In Manchester we were creating our own little storm by producing harm reduction comics with, and for, people with opioid use disorders. I spent much of late 1986 and early 1987 ‘in the field’ with people who were injecting and smoking heroin on a daily basis (people with Opioid Use Disorders – OUD). The method I used is called participant observation. The idea was to get alongside people who were using brown powder heroin and, with them, produce harm reduction information in a format that would be read, shared and discussed.

The characters in the first edition of Smack In The Eye (SITE) were based on real people and the jokes were reflections on real life. In the same year we (Lifeline) opened our first Needle and Syringe Programmes (NSPs). By 1988 we had a team of Outreach Workers working across the North West of England. Our friends and colleagues in Merseyside were engaged in similar activities and had, let the record show, blazed the trail for us at least a year earlier. Looking back at this time our harm reduction work did not have direct, formal links with treatment services. Many of us worked in treatment services but our harm reduction work was truly independent of treatment. For example, the first editions of SITE were distributed by people selling heroin. Some early NSPs were supported by people selling heroin. Those who were selling from houses and flats gave out our comics and our injecting equipment and provided sharps boxes for the return of used equipment.

Fast forward to today and harm reduction in the UK is either nonexistent or provided by professionals inside treatment services. Pharmacies operate most NSPs and those NSPs located within or alongside treatment services are compromised. Opioid Substitution Treatment (OST) is the primary service provided to people with OUD by treatment services. The primary purpose of OST is to reduce ‘use on top’ of the prescribed opioid. The use of other drugs (street heroin, crack cocaine, pregabalin, benzodiazepines and alcohol) ‘on top’ of the prescribed opioid is endemic in the UK and several reviews are underway to try and reduce ‘use on top’.


Naloxone is a life saving medication that can reverse life threatening opioid overdoses. The idea is that Naloxone (“Narcan” in the US) is distributed as widely as possible to users and their families and all first line response professionals (ambulance staff, police, fire service etc, etc). It seems obvious to me that Naloxone should be like rats in London – never more than six feet away from everyone. So, I was taken aback to hear a seasoned OUD treatment expert say that ‘naloxone is a response to failing OST systems’. This was a throw away comment made in the margins of a conference some time ago but it has been haunting me ever since.


If we had Naloxone in 1987 it would have been distributed by everyone we knew in the heroin distribution retail scene. The point is that back then; harm reduction was linked to treatment but was not part of treatment. In the mid 1990s, health authority officials in Manchester initiated a plan to get thousands of people into OST. They were successful and Manchester (like Wirral and Liverpool) soon had a high treatment penetration rate. Most people with OUD in Manchester were enrolled in OST. This same scenario was played out across the whole of England. Today, we are rightly proud to say that the English OUD treatment system has one of the highest treatment penetration rates in the world. Yet, we have worryingly high rates of Drug Related Deaths (DRDs) among people with OUD and ‘use on top’ remains the norm.

In this context, the distribution of Naloxone is a critical harm reduction intervention. However, is the need for Naloxone an indicator of a failing OST system in England and the UK? Personally, I do not agree that it is. However, the failure to distribute Naloxone throughout our system does say something important. I suspect that the failure to get Naloxone out is linked to the decline in discrete and bespoke harm reduction services. I know that some treatment providers are making great efforts to distribute Naloxone and provide NSPs to their service users. It is a real challenge to provide harm reduction services from today’s treatment services.

In recent years these services have been driven by notions of abstinence based recovery and measured by the number of people with OUD who exit treatment via a successful completion and do not return (“represent”) in the next reporting period (six months). People in abstinence based recovery have been recruited to these treatment services as volunteers and workers and are influencing treatment practice and ethos. Whilst this is a positive development in terms of equity and social inclusion it can have a negative side effect in terms of harm reduction.

Back in 1987 our community connections were with people using illicit opioids on a daily basis. Our outreach workers either had personal experience of opioid use, were well trained in harm reduction or both. Many could give direct advice on the intricacies of safer injecting and safer drug use per se. Until the mid-90s push there was no pressure to get these people into OST in Manchester. Harm Reduction was provided to them on their terms with the sole aim of making their own drug use safer. The situation today is that harm reduction, if it is offered, is often provided by people who know little about safer, continued drug use. There is an inbuilt reluctance to engage in harm reduction services provided by these treatment providers if you are also on OST with them. After all, the primary purpose of OST is to reduce ‘use on top’. Attending a NSP means, by definition, that you are ‘using on top’ of your OST prescription. Your key worker may be a staunch advocate of abstinence based recovery and take the attitude of “I did it (abstinence based recovery) so can you”. In recent years progress has been made in treating HCV amongst people with OUD in treatment. If these people continue to ‘use on top’ and do not access NSPs provided by treatment providers there is a risk of re-infection amongst those who have successfully cleared HCV.

So, in summary, is the need for Naloxone an indication of failing OST systems in England and the UK? In my opinion no, it isn’t but the failure to get Naloxone within six feet of everyone who might need it is a critique of the state of harm reduction in the UK. Budgets are falling and treatment contracts are being let and awarded with every decreasing financial settlement. Harm reduction, independent of treatment, is a casualty of public service cuts and a performance management system unable to recognise the importance of keeping people alive. Perhaps the ultimate irony is that people who leave treatment and die can be chalked up as a success in a system measured by the numbers of people leaving treatment and not returning. Grandpa Smackhead Jones will be turning in his grave.

Founding Fathers of Contemporary UK Recovery Movement

Posted on Leave a commentPosted in ABCD, Harm Reduction, History, Recovery, Treatment

This article was published in Druglink, September/October 2011

As the organising principle for drug treatment, harm reduction was not rocket science. Provide needles and syringes to make contact with injection drug users and reduce the transmission of blood borne viruses. Provide maintenance medication to maintain that contact and cut crime. We did this and it worked. However by 2005 there was growing concern that this was not enough, articulated in the NTA‟s Treatment Effectiveness Strategy. Questions began to be asked about whether recovery should be the organising principle for treatment.

In that year, a group of almost twenty commissioners, providers and ex-users met in Manchester to face this challenge from a local perspective. The North West was where the UK heroin epidemic started and we had a disproportionately high drug-misusing population. We discussed the role of abstinence- based treatment and how to move from a focus on quantity to an emphasis on quality. This group gave birth to the North West Recovery Forum, which has been exploring the ways that treatment can be organised to support recovery ever since.
Recovery is now the organising principle of everything we do in the commissioning and provision of substance use disorder treatment. Building recovery in communities is one of the triple pillars of the coalition government‟s Drug Strategy, with its commitment to create a recovery system that focuses not just on getting people into treatment but getting them into full recovery and off drugs and alcohol for good. We have our own UK recovery champions but who inspired and inspires them?

When harm reduction was the organising principle we often looked to Europe and Holland in particular, for inspiration and ideas. With recovery as the organising principle we look to the US and draw inspiration and ideas from four of their most influential recovery thinkers and writers. These are Dwayne Simpson, George De Leon, William L. White and John McKnight. Together they also represent a range of interventions that move from the individual to the collective. The treatment of addiction and „addiction science‟ has focused primarily on the individual. „Recovery‟ on the other hand is focused on fellowship, mutual aid, community and the collective.

Dwayne Simpson (1) first came to the NTA‟s attention in 2005 as a result of the NTA partnership with the Institute of Behavioural Research (IBR) at Texas Christian University (TCU). At that time the NTA were very keen to look at ways of reducing the numbers of individuals who dropped out of treatment very early. Dwayne Simpson is internationally recognised for his work on maximising treatment engagement and retention. But, it was Dwayne‟s emphasis on treatment as a journey that grabbed the attention of the North West Recovery Forum. People on journeys need maps and the International Treatment Effectiveness Project (ITEP) is perhaps most associated with mapping. This was revolutionary to our client group. At a meeting of the North West service user group in 2005 the idea of treatment as a journey was met with a mixture of quizzical and concerned responses. “What do you mean treatment journey? I didn’t know I was going anywhere? I thought I had arrived. I am settled on methadone maintenance. I thought this was it!”
This was met with: “You’re on a train that has MMT (Methadone Maintenance Treatment) on the side and unless you get off then the evidence based destination is the grave”.

Also in 2005 one of Dwayne‟s colleagues was visiting the UK and visited a classic Tier 3 community prescribing centre. They came back to the NTA and said how impressed they were with the “dosing clinic” and looked forward to seeing treatment. They were a little shocked when they were told “that is the treatment”. So, Dwayne Simpson gave us the whole notion of recovery being about movement, journeys and maps. He also prompted us to question whether medication dosing alone should be classed as „treatment‟.

George De Leon is perhaps best known for his work on Therapeutic Communities (2) and the stages of recovery (3). But it was in the work of George De Leon that we first came across the notion of Recovery Oriented Integrated Systems (ROIS). We set ourselves the challenge of trying to articulate or better still, establish a ROIS in a geographically defined community. De Leon‟s work on community as method was crucial in our thinking. De Leon‟s proposition is that by coming together as part of a therapeutic community people can learn how to live right. “Right living” is another of De Leon‟s contributions to the UK recovery
movement. In the past, places like Liverpool had sent significant numbers of people to residential rehabilitation centres far away. Northern regional accents could be heard in residential rehabilitation centres all over the South of England. If they did well they stayed away from their home towns and cities. If they didn‟t do so well, they relapsed and came home. So, North West commissioners of residential rehabilitation were exporting „success‟ and importing „failure‟. Inspired by the work of George De Leon we wanted to see if we could establish a ROIS in Liverpool. Can people get well where they got sick? Can people learn how to live right in the same communities where they had been living wrong? When George De Leon came to Liverpool in March 2011 this question had been answered with a resounding yes.

Liverpool now has a very large and growing network of Narcotics Anonymous (NA). Cocaine Anonymous (CA) and Alcoholics Anonymous (AA) have seen similar growth.
Inspired by the work of George De Leon we have embraced the mutual aid mantras of “I can’t but we can” and “You alone can do it but you can’t do it alone”. Most people start using substances as a communal thing. There was a time when substance use was a fun thing to do with friends and peers. In the grips of active addiction social isolation takes hold, self will runs riot and the addict‟s identity as a victim takes hold: “Poor me, poor me, pour me a drink”. Long term sustainable recovery for George De Leon requires a complete identity change. With this identity change people become pro-social, conventional adult citizens. If their recovery is visible and attractive it becomes contagious. They become role models for recovery. They show that recovery is a reality. They model recovery in their communities and living in those communities becomes a method of recovery.

This is where the work of William L White became crucial (4). William L White is one of the most important thinkers and writers on recovery and recovery communities. At a seminar in London in March 2009, William White employed the metaphor of a dying tree. You can take a tree that is dying and dig it up and replant it in rich soil. If you nurture the tree it can flourish. But, if you dig it up again and replant it in the old soil it will start to die again. The question then becomes, can we enrich the soil so that the tree can survive and thrive without having to be dug up and replanted elsewhere. In recovery terms; can you get well where you got sick? The answer from Liverpool is yes you can or more precisely yes we can. The recovery community becomes a method of recovery. William Whites latest contribution is Medication Assisted Recovery and Recovery Oriented Methadone Maintenance. This work reminds us that there are many paths to recovery; all are a cause for celebration and that includes people on methadone and Buprenorphine. The best treatment will prepare you for ongoing support in a community. Commissioned treatment systems can support but not provide long term recovery. Long term recovery is sustained and maintained in fellowship and mutual aid in recovery communities.

By 2009, it was becoming clear that there was a piece of our recovery jigsaw missing. What happens to people in long term recovery? Do they just stay in 12 Step and SMART Recovery meetings? Where else do they go and what do they do? We had come to believe that people in long term recovery were “better than well”. This is where the work of John McKnight and his colleagues fits into the UK recovery picture. Asset-Based Community Development (ABCD) has emerged as a way of responding to the challenges posed by general health and social inequalities (5). The most difficult and complex cases of addiction, presenting to public services for treatment, tend to be emerge from, and are located in, the most impoverished communities. Treatment alone cannot provide a long term answer to addiction that has its roots in intergenerational health inequalities.

As the treatment system prepares for the transition to a new public health system, under the auspices of a new body to be called Public Health England, the NTA is already encouraging local areas to adopt asset based interventions. Its action plan for 2011-12 makes clear this approach will enable partnerships to assess the recovery networks of their own communities as part of the local strategic planning process. Treatment that is recovery-oriented and recovery that is asset- based can ensure that our sector plays a major role in our new public health system. People recovering from addiction in the same post codes that they were sick are real community assets. They show that new and healthier identities can be forged by coming together and creating communities that foster recovery in the widest sense of the word.

(1) http://www.ibr.tcu.edu/persons/simpson.html
(2) De Leon, G. (2000). The therapeutic community: Theory, model and method. New York: Springer Publishers, Inc.
(3) De Leon, G. (2005) Stages of Recovery Univ. of California at San Diego (UCSD) Center for Criminality and Addiction Research Training and Application (CCARTA)
(4) www.williamwhitepapers.com
(5) http://www.abcdinstitute.org/profile/?ProfileID=47&/JohnMcKnight/

Residential Rehabilitation – A Confession

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I have never liked the idea of Residential Rehabilitation. I never understood the ideas behind the different models of Residential Therapeutic Communities. I had never heard about residential rehabilitation until 1984 when I was interviewing young heroin users in the North of England. I knew a lot about drugs and had been using them myself since my first encounter with benzodiazepines in 1969 at the age of 12. One of my closest friends from primary school died from a barbiturate overdose in his early twenties. Until 1995, I had known many people who had died from drugs (barbiturates and opioids) but I had never seen anyone ‘recover’ from ‘addiction’ (Substance Use Disorder).

In September 1985 I was employed as the manager of one of the first Community Drugs Teams in Trafford, Greater Manchester. Lifeline was started in 1971 by Rowdy Yates and a small group of ‘addicts’ and a supportive doctor called Eugenie Cheesman. Rowdy was, and is, an inspiration to me. He is one of my, very few, drug sector heroes and he remains a good friend (I hope). However, I never understood the fixation on sending people away from the North West of England to residential rehabilitation. Some of the rationale included getting the ‘client’ away from ‘triggers’ in the places where their problems had originated. I never understood this because by then I had started to develop my own alcohol problem. As I sat watching TV during one of my countless DIY detoxes from alcohol I had to sit through alcohol adverts. I had to walk past pubs shivering and knowing that I had the money to go in order a large brandy and port and a pint of stout (my favorite morning tipple).

I could never understand why ‘addicts’ had to be sent away, out of area, to residential rehabilitation whilst ‘alcoholics’ like me (I never admitted this till 1995) were sent to the local psychiatric hospital (the notorious ‘Ward 15’ in Bury) for a detox and then sent home. What happened in those residential therapeutic communities seemed to me like some bizarre therapeutic cabaret. Chairs and benches seemed to be essential props. There were benches to sit on if you had been naughty and chairs to talk to if you wanted to vent at a loved one who had died or done you harm. You could impersonate fruit and walk round with a placard saying ‘I am a liar’ and ‘I am a thief’.

I never understood what all this had to do with recovering from a heroin habit you had picked up on a council estate in Bury. It wasn’t just me either. In 1985 a friend from Bury (who I had used drugs with) was in court for a string of offences committed to get the money to buy heroin. He passed through Lifeline’s Induction Programme and went to residential rehabilitation centre as an alternative to prison. From memory he was there about 9 months. When he came out went for a pint and he told me all about it. He said it was a laugh and, once he realized he couldn’t head butt the counselors ‘in group’ he did OK. After a couple of pints he said “right great to see you, I’m off to score some ugly dust (heroin)”.

Variations on this scenario played out over the years and I came to regard residential rehabilitation as a bit of a joke. There is the possibility that my perspective has always been tainted by the fact that I have always lived in Bury (apart from a brief exile in Bradford) and mix with people I grew up with on an almost daily basis. When I first sought help for my own alcohol problem it never even occurred to me to go anywhere other than 12 step mutual aid. Unlike my negative experience of people from Bury going away to these residential rehabilitation centres, I knew some real alcoholics (who I had drank with) who had stopped drinking by going to Alcoholics Anonymous (AA). Residential rehabilitation if discussed was dismissed as a joke but AA was treated with a degree of respect because people had seen the change in people like ‘Terry from Bury’.

Fast forward to 7th September 2018 and I am sat in the audience at the recovery conference and I hear David Best talking about building recovery communities by connecting people to hope. He seems to say, or I choose to hear him say, that sending people out of area to residential treatment is harmful because it doesn’t add to the local therapeutic landscape. I get excited and start to tweet. In the haste to tell the world that one of our leading, bone fide academics on recovery is presenting evidence that says ‘keep it local’ I fear I may have over egged the pudding. If I have, I want to publicly apologize to David Best for misquoting him. However, I do want to state, for the record, that I certainly think that if people do need residential detoxification and residential rehabilitation they should stay as near to home as they can.

We do recover and we can get well where we got sick. When we are ‘recovered’ or ‘in recovery’ and walk through our local shopping centres, people who know us, who drank and used with us but are stuck in the madness see us and they can connect to hope. They can’t do this if they are recovering 250 miles away on the recovery Riviera. Finally, I want to dedicate this rant to ‘Terry from Bury’ who planted a seed of hope in me that grew roots and 23 years later sprouted and gave me a life beyond my wildest dreams. The photo is of the author in 1981.







Giman Bradford 1981

Yin and Yang: Successful Completions and Recovery Communities

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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.

Why psychiatry?

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This piece was primarily stimulated by conference presentation by Dr Colin Drummond that you can find on Lifeline’s FEAD website.

If Colin thought that psychiatrists were demonized by commissioners and the NTA, he really needs to look and see what the recovery lobby have got to say about them. Anyway, somebody raised the question of why psychiatry should be responsible for drug treatment in the first place.

To answer that question, you have to look back at the demise of the old British System. Prior to the 1960’s, heroin addicts in the UK were invariably drawn from one of two groups. They were either ‘therapeutic addicts’, people who had gotten dependent on opioids as a result of having been prescribed them for pain relief. Or they were medics — people who had access through their jobs. These people were largely indistinguishable from the rest of the community and so the old British System — prescribing them sufficient heroin to meet their needs — worked well.

This began to change at the start of the 1960’s when the media and the Home Office both began to notice an upswing in a ‘new’ type of heroin user. Unlike the previous groups, these tended to be young, criminally deviant with attitudes that challenged the system. Rather than keeping to themselves and just using their scripts, these people seemed to be socializing with and ‘infecting’ other young people. Consequently, the prevalence of heroin use (and addiction) was growing exponentially.

So in 1961, the government convened a committee of the Great and the Good to look at the issue and decide whether anything needed to change. But doctors guarded their independence with great vigour, and argued that the current system was working well.

Rather than settling down though, the problem just kept on growing. The papers were starting to report some of the excesses associated with the old British system. You had the likes of Dr Petro, setting up his clinic in the cafe at Piccadilly Underground, selling heroin scripts at £3 a time to get the cash to go gambling. Or Dr. Frankau, who seemed to keep a staff of servants drawn from her patients.

When the Brain Committee was reconvened in 1964, they decided that the dramatic growth in overprescribing was really a function of this small handful of overprescribing doctors. It’s certainly true that that’s where the drugs were coming from in London. The demand for amphetamines on the mod scene was fuelling pharmacy break-ins in other parts of the UK, but there certainly wasn’t any significant quantity of imported illicit heroin until we started seeing small quantities of imported Chinese heroin on Gerard Street in the early 70’s.

The Brain Committee then, decided to put an end to the old free-for-all, in which any GP could prescribe any drug they liked, in any quantity, to any heroin addict that was their patient. It recommended the establishment of a number of specialist treatment centres — which came to be called Drug Dependency Units or DDU’s — that would be responsible for the treatment of heroin addiction. If a doctor wanted to prescribe to addicts, they had to have a Home Office special licence that would allow them to prescribe heroin and cocaine. (In the mid-70’s, Diconal was also added to this list — a measure that saved a lot of limbs, as well as a lot of lives.)

And who was to staff these Drug Dependency Units? Well, addiction was viewed primarily as a psychological problem, so didn’t it make sense to staff the units with psychiatrists? And thus begun the long term relationship between psychiatry and treatment for drug dependency that lasted for for nearly 50 years in the UK, but that Colin Drummond feels today is under attack.

And Professor Drummond isn’t wrong. When I entered drug treatment in 1975, I’d see a Consultant Psychiatrist twice a week. Some were awful, but the majority of them were humane, intelligent people who did their best for their patients.

Although the guidelines say a patient should be seen at least quarterly, in many services it’s not unusual to be seen every six months — perhaps even every year. And you might be seen by an unskilled, unqualified ‘Recovery Coach’ who’s volunteering after being six months drug free.

We used to pretend drug treatment was a ‘Cinderella service’, but for most of the last fifteen years, it’s actually been a ‘Sleeping Beauty’ service, and as the princess lay sleeping on her bed, the world was passing her by.

Today, we’re in a new world, and as Professor Drummond astutely points out, it’s unlikely that the pendulum will ever swing back to where it used to be.

Peter McDermott

Stations of the Lost and Found

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ladderstations of the lostpin ball

Stations of the Lost: The Treatment of Skid Row Alcoholics by Jacqueline P. Wiseman was first published in 1970 and won the C. Wright Mills award for best book in the area of social problems. It gave us the view of the alcoholics who passed though all the places those skid row alcoholics pass through and the view of those working in these places. I have been thinking about this book a lot recently because it always made me think of a pin ball machine. You get shot out of the chute at birth and you bounce around the bumpers doing well and getting the prize – a free game – or you get a couple of bad bumps, get a miserable score and slide back down the chute – game over. Once I had exhausted the pin ball metaphor I tended to think of it like a form of Jacob’s ladder that went both ways – up towards heaven and down towards hell. Several years ago I was stood talking to a friend who was then a drinking alcoholic in Piccadilly Gardens in Manchester. As we were talking another guy came up who “looked like he’d fell off a flitting” (as my Mother would have put it). “Excuse me lads, how do I get to Val’s Hotel?” (Which at the time had a reputation as occupying one of the lower rungs on the descent of Jacob’s ladder?). Quick as a flash my mate replied “Carry on drinking and don’t pay your rent!” We are now working out how recovery housing works in Greater Manchester, Cheshire, Lancashire and Cumbria. As part of this process we might do well to start by thinking how the down ward escalator works. Each of our 152 local authority areas in England will have its own Stations of the Lost. These are the places that people pass through on their way down into the hell of active addiction, social isolation and premature death. Besides the police stations, prisons, hospitals and treatment centres there are hostels and bed and breakfast hotels. Once we have mapped out the rungs of the ladder on the way down we can begin to map the way out and upwards. We can offer Stations of the Found. These are the places where you find people in recovery climbing away from addiction, social isolation and premature death and towards the sunlight of the spirit of recovery. The lower rungs might be a sofa or a spare room in the house of someone else in recovery. The higher rungs are total freedom in your own home with a job, friends and family. So, what do the stations of the lost look like in your town and are they matched by stations of the found?