Addiction and recovery research – time for change

An article by guest blogger DJ Mac…

Time-for-changeSMMGP has a great downloadable presentation on addiction treatment research. By Jim Orford, it’s a couple of years old now, but it has not lost any of its relevance. I’ve been writing on the problem of lack of addiction research generally and a definite near absence on recovery research. But we don’t want research for research’s sake; we want addiction and recovery research that is asking and answering the right questions. If we were to come at addiction and recovery research from a different direction, would it help us in a way that traditional approaches have not?

Orford is a Professor of Clinical and Community Psychology at the University of Birmingham. He sets out some of the problems with existing research – why it ‘fails’:

  • It assumes a technological model of treatment
  • It adopts a narrow focus on time-limited professionally dominated treatment
  • It uses an out of date, restricted definition of science and knowledge production

Technological model of treatment

He make a very relevant point around the ‘Dodo Bird Effect’ – the outcome equivalence paradox which views the therapist in an addiction treatment setting as a technician delivering a ‘treatment’ and neglects what we think we know is at the heart of helping people move on – the quality of the therapeutic relationship. So we measure the treatment as the dominant intervention, rather than the personal relationship. The problem with this, argues Orford is that many treatments end up providing much the same kind of outcomes (think Project Match).

His tentative conclusion:

Well-delivered, credible, named treatments are, in most important respects, the same, which would account for supposedly different types of treatment having equivalent outcomes.

Professionally dominated treatment

The problem with professionally dominated treatment is that it tends to ignore professionally unaided change (or, in my experience, resists it); ignores the settings and systems in which treatment is embedded; neglects wider social networks like family and community resources and defines outcomes narrowly. If recovery takes place more in communities than in clinics we are going to miss the impact of community recovery capital on outcomes, something I touched on before.

Restricted definitions of science and knowledge production

Here lie dangerous pitfalls. Research can miss the importance of culture and assume that the findings will be universal. Orford lists more problems:

  • Which assumes research is value-free and researchers are neutral
  • Which privileges top-down expert theory over tacit, implicit knowledge
  • Which ignores the patients view

These chime true for me. The value of lived experience and of recovering people, peer supporting in services has largely been unrecognised. What the patient wants can be lost in delivery of what ‘the evidence’ says works. “Successful” treatment can be one where the patient never reaches his or her goals, but agreed outcomes are still achieved. The service may end up more satisfied than the patient.

In addition there are amazing things happening in recovery communities, in mutual aid groups and in family support services, some of which are peer-led. This is community inspiration, asset building and growth and it is largely not being captured.

Solutions

The prof is not just identifying the problem; he has some suggestions:

  • Stop studying named techniques and focus instead on studying change processes and developing good addiction change theories
  • Study these processes within broader, longer-acting systems of which treatment is a part
  • Bring the science up to date by acknowledging and using the variety of available sources of knowledge (e.g. qualitative research, action research and participative research)

The part that other recovering people (peers) play in recovery from addictions is becoming clearer, at least to those who have eyes to see it. Community recovery capital is on the radar a bit more. Those of us working in treatment need not be afraid of acknowledging that there is more to getting well than professional interventions. When you ask someone in long term abstinent recovery what helped them get there, treatment figures, but it’s not necessarily top of the list and the technical aspects of treatment will hardly be mentioned.

What will be remembered is how kind professionals were, whether we listened to the story, empathised with the struggle and kept faith in them, even when the client struggled to believe in his or her self. In other words, exactly the sort of stuff that traditional addiction treatment research doesn’t measure.

It’s time for change.

DJ Mac

See DJ Mac’s original blog post here
@DJMac_

Jack and Bill from the service up the hill

Dr Steve Brinksman writes the regular “Post-its from Practice” articles for Drink & Drugs News (DDN) Magazine. The most recent Post-it (Jul-2014) appears below with kind permission from DDN.

It is my firm belief that the majority of people with drug and alcohol problems can be managed in primary care, albeit with the proviso that appropriate access to psychosocial treatments are in place. I was initially therefore fairly downbeat about having to refer Bill back to our local secondary care provider.

He and his brother Jack are both registered at our practice and have been for a number of years. Now in their late forties, they each have a long history of chaotic IV polydrug use and alcohol dependency punctuated by numerous prison sentences.

Over the years their lifestyle has taken its toll and they both have a number of physical health problems mainly related to alcohol use and previous encounters with mental health services with diagnoses of explosive type personality disorders.

Jack, the older of the two, was being treated by the secondary care drug service for a number of years when we were approached to see if his care could transfer to our practice as due to some of his other problems attending the CDT was becoming more difficult. In the 3 years since then there have been spells when he has lapsed into more problematic drug and alcohol use, however with a lot of input from his keyworker based at our surgery we have succeeded in integrating his care into our practice. This is also testament to the skill of our receptionists who have managed to build a good rapport with him that on the whole nullifies his occasional outbursts.

Perhaps feeling flushed with success we then agreed that his brother Bill’s opioid prescribing could also be transferred over from the secondary care provider to us. Despite trying the same approach as we used with Jack, this has been much less successful. Three local pharmacies have barred him due to abusive language and he would regularly cancel or not attend key worker or doctor appointments, only showing up finally if the script was altered. His alcohol use escalated and he was verbally offensive to the receptionists on several occasions despite this being discussed with him by both doctor and keyworker.

We have a policy of discussing patients with any conditions whom we are struggling to manage either clinically or behaviourally at our weekly practice clinical meeting. As a result of one of these discussions it was decided to transfer Bill’s care back to the secondary care drug service.

This was a difficult decision to make and made me realise that whilst we may be fortunate within our team to have the clinical and case management skills available to support less stable people the roles of other staff and colleagues are equally important. Primary care is a fantastic place to deliver care to those using drugs and alcohol problematically, however some will need extra support and care and I am grateful that additional services are available.

Bill still comes to see me and we are now starting to address some of his physical and mental health issues and our discussions are no longer dominated by requests for changes in prescriptions. I hope that at some point in the future he may again receive all of his care at the practice but for now transferring his opioid substitution treatment out has meant he has remained a patient at the practice. For all concerned – a positive outcome.

– Dr Steve Brinksman
Birmingham GP, SMMGP Clinical Director, RCGP Regional Lead in Substance Misuse for the West Midlands

Note: Previous Post-its from Practice can be found in the Resource Library on the main SMMGP web site.