Update, 12th July: It’s been pointed out to me`by various sources that time-limiting methadone prescribing is possibly a stalking horse for other changes the NTA wish to make. Nevertheless, as one commentator suggested, such political “clodhopping” is completely at variance to the spirit and ethos of recovery. Stalking horse or not, the points made in this piece remain germane.
Introduction
The National Treatment Agency (NTA) published documents last week relating to their board meeting of the 6th July. Reading the three-page business plan for 2010/11 we discover that time-limiting methadone prescribing could very well become a reality in the next twelve months
I’ve printed the second page of the business plan in full below, with highlights and annotations of my own to accentuate the contentious content. The language is innocuous, but suggests far-reaching and potentially destructive consequences that represent a huge step backwards into the dark ages of drug treatment. This is a great disservice to the service users and staff who aspire towards providing world class services and completely irreconcilable with a recovery orientated treatment system that acknowledges – fundamentally – diverse needs and diverse outcomes.
Sidelining key challenges in the field
We are now faced with a situation where the real challenges in our treatment system – the lack of integration, the paucity of recovery-orientated methadone treatment, the implementation of recovery orientated treatment, the suffocating and restrictive practices of clinical governance etc…. all of these challenges will now be sidelined by this juggernaut of a governmental regime dedicated to restricting methadone prescribing and in doing so consuming vast amount of resources, further alienating an already disenfranchised and unsettled workforce, and of course effectuating disengagement from treatment and for some, heartbreakingly, hastening their path to death. All to accomplish this astonishingly ignorant and ill-informed piece of bureaucratic folly.
I should point out my support for the NTA in this matter. I do not believe this initiative came from within the special health authority, but from pressure from the government. This is pure speculation, but of course no surprise to those who have been monitoring the situation.
Other sources of information
Peter McDermott, inventor of harm reduction, the Alliance’s PR guy (currently on secondment), NTA board member, and one of the most decent human beings you could hope to encounter was present at the meeting and expressed his feelings after a period of reflection in typically articulate, astute and passionate bearing over on the Alliance forum. Peter’s post and the associated thread thread can be found here: , but there are a numbe of discussions taking place (see for example this piece by staff member Jules) and it’s well worth taking time to soak in the experience and expertise that abides in that forum. If anyone comes across other documents or discussion relating to this – please do drop me a line
The relational identity of methadone
The ambivalence that surrounds methadone seems to rooted in the fact that we ascribe agency to methadone. It becomes an actor with intentions, motives, desires. It is humanised, and then demonised. In fact, it is a neutral chemical compound. It’s agency and character are configurred in the relationships that are formed between methadone, individuals, services, institutions, justice services the popular and academic press.
This network of relationships defines methadone. The character and quality of those relationships will determine whether the relationships are positive or negative. By restricting methadone prescribing one instantly sours the whole network involved in the governance, management and consumption of methadone with the fetid milk of claustrophobic therapeutic expectations.
I’ll be writing more on the relational identity of methadone in my next post, towards the end of this coming week.
The instrumental role the recovery movement can play in this debate
This is a chance for the recovery movement to demonstrate it’s integrity and commitment to a broad, panoramic vision of recovery that acknowledges the instrumental role that methadone maintenance therapy (MMT) can play in individual recovery journeys. As anyone in the field will tell you – clients needs vary enormously. For some, long term MMT may be the best recovery option. For others, particularly the most dislocated members of societies it may take a few years of stabilisation and maintenance before they are ready to move towards abstinence. It is hard to grasp how the NTA can introduce recovery orientated treatment, whilst hamstringing a key recovery resource – MMT. The idea of limiting methadone prescribing is completely antithetical to authentic recovey orientated treatment
I believe this issue is particularly significant for the recovery movements in the UK as it will help define and clarify the frontiers, boundaries, material and formal objects of our work.
I do not expect everyone to share this view. There will be those that believe that restricting methadone prescribing is a positive step forward, something to be welcomed. Over the next few posts I’m going to demonstrate why I believe this is not the case, and why vocal opposition to this proposal by those in the recovery movement is absolutely vital.
- Stephen Bamber, 11th July 2010
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Re. stalking horse argument — I’m not seeing it. Not seeing what possible changes the NTA could want to make that would meet with significant resistance. Any clinical changes would require a change to the clinical guidelines and the last lot (less than three years old now?) really represents a consensus between all the various views among expert clinicians.
The localism agenda means that the NTA have lost the strong performance management role they once had, so it’s hard to see what they could impose. AFAICT, that Times piece (and the lovely people at Addiction Today) make it very clear that this is a govt. agenda via IDS/CSJ.
Thanks Peter. I share you view on this. It’s fairly obvious that this is a government intervention. The pre-election positioning and the ramping up of the rhetoric over the past year make it quite clear what the agenda is.
Re ‘stalking horse’ how about this; put out a statement that’s guaranteed to generate huge amount of anxiety whilst refraining from actual detail. The ‘abstentionists’ jump up and down believing their day is finally here whilst the harm reductionists perceive decades of valuable work and research is about to be trashed at enormous cost to countless people. The two sides, who have not exactly been keeping the peace, begin to step up the ‘war’ between each other. Further confusion is generated and the word ‘chaos’ begins to be banded about. Up step certain individuals saying, “look at this lot..see what will happen if you do away with the NTA” or perhaps “look what will happen if you do away with us..find us a new home (National Addiction Recovery Board anyone?) please and we’ll sort it all out”. Clearly we are looking at a government intervention, supported by some individuals who champion ‘Recovery’ whilst apparently having little understanding of what this means, but I would not discount political manipulation on the part of those who have a vested interest in the status quo. I think we are going to see rather a lot of this sort of stuff.
I think it is really important that we step up the building of alliances and work together to generate British Recovery Models that reflect abstentionist approaches and the views that you’ve expressed in your blog Stephen. I actually think we have an opportunity here and would welcome (as would the UK Recovery Federation) engagement from those who wish to set a progressive agenda within Recovery Communities and Recovery Oriented Services. What’s crucial is that we do not get sucked into fundamentalist positions which leave us mired in conflict whilst those with little understanding of ‘Recovery’ throw out the baby with the bath water. We need to educate and we need to learn.
Come on deep breaths now, we have all been here before.
Mid 80’ s: name that script (unfettered prescribing)
Early 90’s forced reduction (revolving door referral system)
Now high dose maintenance (perception that too many are on methadone)
All of these changes were essentially the product of political interventions and these proposed changes are in the same vein, some say, in part influenced by opinions from service users and ex service users.
The NTA can and does attempt to buffer some of the effects from the reactionary politics that can surround substance misuse and in this sense is not best supported by some of the factional histrionics we have already seen.
The arguments of the previous few years serve to demonstrate a lack unified thought, the absence of which opens the door the kind of political gerry mandering that has dogged the drug treatment system since its inception.
Methadone prescribing is the fulcrum of the treatment system and how it is placed will affect the whole balance and emphasis. Its evidence base for effectiveness is short and can only demonstrate short term effectiveness. Wider data looking at the health/socio economic benefits for service users and society are unclear, yes it reduces deaths and crime in the short term, however it is unknown if these effects are maintained for much longer periods.
There is a discussion to be had about periodic reviews of an individual’s methadone prescribing to ensure “you’re getting some significant benefits from it” in relation to recovery goals as opposed stagnation.
We are not going to win influence with self indulgent saber rattling or one trick pony backing. I have no problem with the concept of there being too many in methadone prescribing or that it can be counter productive for service users. Neither do I have a problem with services users making their case for methadone prescribing for as long as they feel they need it.
I do have a problem with arbitrary time limits being imposed upon methadone prescribing. It is incumbent upon us to offer solutions that deliver recovery results that are understood by wider society, less they impose their own.
The whole ‘unfettered prescribing’ thing is a bit like Rashomon. Even here in Liverpool, supposedly the home of pharmacological anarchy, doses were mostly limited to 40mg prior to the ACMD’s arrival. In most parts of London, unless you were on a grandfathered script since the 60′s, you were gonna be time-limited to a 28 day community detox. One of the reasons that we don’t have time limited prescribing today is because somebody, somewhere has a whole load of data on the levels of BBV infection and drug related death that occurred during those ‘enlightened’ years.
Agree about the importance of regular reviews. However, I’ve yet to hear a coherent argument about what’s supposed to happen at this point. Is it the people who are doing poorly, or the people who are doing well who get thrown off after these reviews? Both routes present significant risks, IMO.
One of the strengths of the fellowships in the past was their emphasis on attraction rather than compulsion, and it seems to me that this is always true of abstinence based treatment. If we can offer people a real shot at a visibly better life, most people would snatch it with both hands. But the drug treatment field has always struggled to present a convincing vision of this. As the number of visibly recovering people in our communities increase, this process is starting to happen more and more, but it’s not going to happen overnight. And the impact that it’s likely to have on the average natural history of an opiate dependence — currently 20 years without treatment, reduced to 12 with treatment — is unlikely to shrink dramatically whatever we do. The issue for me is how treatment impacts on the quality of people’s lives during that period of active addiction.
I think that we are back peddling to pander for the benefit of public opinion. I do not see a value in placing restrictions on methadone treatment, surely that is a matter of assessing what is in the best interest of the person being prescribed, and I am pretty sure that is best achieved as an individual matter, as one size rarely fits all. I am curious as to how these changes to methadone prescribing have anything to do with recovery? As far as I am aware, recovery is a person’s journey of reclaiming their life and citizenship as determined by them, as an individual; as such, is not something that is determined by prescribing or professionals or even necessarily about abstinence. If anything, restricting the options available to the individual is likely to limit the ways in which a person can stabilise their lives sufficiently to make changes. History tells us that abstinence as first line treatment works for some, but not for all. What happened to harm reduction?
All things rashomon, I can, I hope, be forgiven for looking back with rose tinted shades, less forgivable would be to look forward.
Interestingly where pharmacological anarchy was suppose to have reigned; in practice it actually appears to have been comparatively restrained. However London and Liverpool were not the only places of activity at this time and a quick review GMC’s disciplinary proceedings during the 80′s tells its own story.
The BBV argument is more difficult to sell after a prolonged period of increased BBV infection rates. As to a coherent argument for people doing poorly or well those doing well I assume would be offered interventions supportive of further progress and those poorly offered alternative solutions and in that sense it is somewhat desperate attempt to increase the options. The point I feel is that it’s not ok to see people on methadone indefinitely without a secure rationale this at least is equally aimed at the treatment system and professionals as it is service users.
I could not agree more with your comments about the fellowship. It is a shame we have not employed a similar tactic in attracting the public and political understanding of the recovery process as opposed to attempting to compel it.
Yes its not going to happen overnight but I do not share your level of pessimism about the time frames. The issue for me is how the quality of someone’s recovery impacts on their life, how much is methadone’s role in this is a moot pointbut I find the vision more convincing.
Sorry to be a stick in the mud here Peter
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