Task force to review services for drug misusers

Abstract

In the past ten years there has been enormousgrowth in the size and the range of services forpeople who misuse illicit drugs. The blueprint forservice development was a report from theAdvisory Council on the Misuse ofDrugs entitledTreatment and Rehabilitation (Department ofHealth and Social Security, 1982). In response,growth of the non-statutory sector was particularly encouraged and the whole venture wasfunded through a series of Department of Healthinitiatives aimed at both the prevention of thespread ofHIVinfection and the ofdrugdependence. The time was right in the mid-1980s for the renaissance of harm reduction.The government was willing to accept anymeasures to prevent an AIDS epidemic, non-statutory agencies were in the ascendancy, andthe fieldlacked any convincing viewon treatmenteffectiveness. Guidance from the Advisory Council on the Misuse ofDrugs (Department ofHealthand Social Security, 1988; Department ofHealth, 1993), however, was careful not toendorse wholesale adoption of a harm reductionapproach, but rather to see, for example, needleand syringe exchange schemes and substituteprescribing as useful elements of a public healthstrategy which both contained the spread of HIVand initiated the process of becoming drug free.The Department of Health has run an effectiveHIV control programme but, as perceptions ofrisk from HIV have diminished, new concernshave come onto the drugs agenda for the late1990s. Fear of an AIDS epidemic has beenreplaced by fears of criminal activity, and thependulum has again swung against too liberal aninterpretation of harm reduction. Prescribingdrugs for drug misusers has always beencontentious and expensive; therefore, a reversalofthe harm reduction policywas expected when,in 1994, Ministers set up a task force to reviewthe effectiveness ofservices . . in relation to theprincipal objective of assisting drug users toachieve and maintain a drug free state ...(Department of Health, 1996a). The task forceconsisted of 11 members.Tackling Drugs Together (Department ofHealth, 1995) committed the Department ofHealth to produce purchasing guidance for1997-1998, based on the task force review.Tackling Drugs Together identified a reductionin the acceptability and availability of drugs toyoung people, an increase in the safety ofcommunities from drug-related crime, and areduction in the health risks and other damagerelated to drug misuse as key elements ofgovernment strategy. In response, the task forceset out to map and categorise existing services,and to conduct a multi-centre study of treatmentprocesses and outcomes, referred to as NTORS(National Treatment Outcome Study). NTORSisa prospective, uncontrolled trial which hasrecruited 1110 subjects. The central finding fromNTORSso far is that treatment works in termsof reducing drug involvement, improving health,reducing criminal activity, and improving psychological well-being.All four modalities investigated (in-patient, residentialrehabilitation, methadone maintenance andmethadone reduction) have shown benefit, maintained at six-month follow-up.It is of interest formental health workers that the percentage ofpeople reporting feeling hopeless about thefuture fell from 63 to 44% and those expressingsuicidal thoughts from 29 to 16%.The follow-upwill continue for fiveyears.The task force is imprecise in categorisingmethadone programmes and is content thatany prescribing programme delivers both socialand health benefits. However, Raistrick (1997)has argued that the specific purposes of substitute prescribing must be understood by bothpurchasers and providers. These purposes, mostsimply characterised as social control, individualtreatment of dependence and protection of thepublic health, have implications for the source offinance, case management and service deliverysystems. The Amsterdam model (Plomp et al,1996) has successfully operationalised roles forgeneral psychiatrists, general practitioners andpsychiatrists specialising in substance misuse,and recognises that doctors are used to caring forindividuals rather than acting as agents of socialpolicy. Clarity of purpose should form the basisof substitute prescribing.Surprisingly the task force rather neglects therole of the general psychiatrist. This is