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may need to be continued indefinitely – for as long as the individual concerned
finds it helpful. You can search the literature for as long as you like, but nowhere
will you find a clinically valid argument suggesting that OST only be provided for
a time-limited period.
Since the release of the ‘recovery roadmap’ there has been a slew of further
publications, with varying degrees of government backing, many of which have
sought in various ways to disavow some of the more extreme positions taken by
the former. Notable among such documents is
Medications in recovery:
re-orientating drug dependence treatment
by John Strang and colleagues, which
back-pedals considerably from some of the more blatantly ideological positions
taken by the ‘recovery roadmap’. It disavows the notion that OST should be
arbitrarily time-limited, instead insisting that services ‘ensure exits from
treatment are visible to patients from the minute they walk through the door.’
Because of the crucial indicator embedded in PbR, as discussed above, many
will be discouraged from entering into OST programmes. For many people who
are experiencing problems with their drug use, knowing that they can access OST
has long provided a crucial life raft of stability. This new agenda punches holes in
the life raft and seems to be predicated on the notion that one has to jump, or be
pushed, off of it as quickly as possible. The risks of doing so are enormous, not
least of all in terms of the dangers associated with relapse, notably overdose,
destabilisation, and increased vulnerability.
The consistent messaging has been that, as Duncan Selbie put it to me, ‘being
maintained on methadone’ should not be seen as the end point. However, for
many of us, all that we want, all that we need, is to be secure in the knowledge
that our scripts will not be terminated on any grounds other than that of a
mutual agreement to do so, and even then only in a carefully managed reduction
schedule. Those of us who want and need nothing more from our drug services
than respect, dignity and a maintenance script are being told very clearly by this
government that our lives are less valid, that our choices are less legitimate, and
that unless we knuckle under the cosh of a state-imposed notion of sobriety,
abstinence and temperance, that we will have our benefits taken away, our
children removed, our housing and employment threatened.
Selbie’s comments reiterated the moral imperative contained in the
Putting
full recovery first
document, which, prefaced by Lord Henley, was guided by the
notion that ‘our ultimate goal is to enable individuals to become free from their
dependence fully and live meaningful lives.’ The notion that those of us on
pharmacotherapies cannot live ‘meaningful lives’ is an insult to the many tens of
thousands of us who are on long-term maintenance scripts, who are accessing
harm reduction services, and are, at the same time, succeeding professionally
and personally. Equally this agenda does nothing to give confidence to those who
rely on them that friendly, comprehensive harm reduction services will be
available and properly funded.
The agenda is highly irresponsible in its attitude towards needle and syringe
programmes, stating that ‘it is self-evident that the best protection against blood-
borne viruses is full recovery.’ This statement flies in the face of the well-
developed, internationally accepted evidence base that shows that the provision
of comprehensive needle and syringe programmes is the most efficacious means
of preventing blood-borne virus transmission among injecting drug users. Equally,
the same evidence base demonstrates that for many, accessing NSPs is often the
route out of illicit drug use and into pharmacotherapy programmes.
The new recovery agenda – with its marches, boat rides, right-wing Christian
overtones, Russell Brands and happy-clappy ‘recovery champions’ – silences,
stigmatises and further marginalises those of us who are either active drug users
or are stable on maintenance scripts. It demeans our choices and denigrates our
successes, and it does so on the basis of a disregard for the overwhelming body of
evidence that recognises the complexity of drug dependence, and demonstrates
the vital need for comprehensive harm reduction services. These services must
cater for the drug-using community in all of its diversity, and not through a ‘one
size fits all’ puritanical agenda. If there has ever been a time for the drug-using
community to come together in defence of harm reduction, it is now.
Dr Eliot Ross Albers is executive director of the International Network of
People who Use Drugs (INPUD
)
POLICY SCOPE
I attended a roundtable meeting on HIV and
injecting drug use
at City Hall in London in
January. It was hosted by the National Aids Trust
(NAT) and I was struck by an observation from
the chair at the beginning of the meeting. He
said that he had yet to receive an invitation to a
discussion of the future of harm reduction
hosted by the drug sector, as there didn’t appear
to be much activity around this agenda.
Leaving aside the specific debate about the
role of opiate substitution treatment, I can see
how someone external to our sector could get
the impression that ‘harm reduction’ is slipping
off the drug policy radar. Has an increased focus on ‘recovery’ been at the
expense of ‘harm reduction’ perhaps? This is too simplistic. For example, the
second of eight ‘recovery outcomes’ in the
Drug strategy 2010
is the
‘prevention of drug-related deaths and blood-borne viruses’. The lack of
discussion of services like needle exchange may actually be because their
role in treatment systems is all but universally accepted. There may be a
Maslow’s Pyramid effect – the harm reduction legacy appears secure and so
we move on to other kinds of needs, like relationships, housing, education
and employment.
Two of the main messages from the NAT meeting should help to put harm
reduction more firmly back on the drug policy agenda. First, there are new
harm reduction challenges. For example, there is growing concern about
high-risk drug use and sexual activity among some sections of the gay
community, including injecting of drugs like methamphetamine. This is not a
group who would necessarily access traditional drug services, including
needle exchange. Similarly, DrugScope’s annual street drug survey identified a
growing cohort of people injecting mephedrone. Steroid use remains an
issue, as, apparently, does the sporadic phenomenon of young women
injecting melanotan, reported at the NAT event.
Secondly, what will be the impact on harm reduction of radical changes in
commissioning structures in a period of austerity. While it was recognised at
the NAT meeting that harm reduction could be a good ‘fit’ within a public
health framework, the rise of localism raises some fundamental issues about
mechanisms for ensuring an adequate level and standard of potentially life-
saving services for people with drug and alcohol problems.
Bluntly, as someone asked at the NAT event, what are the safeguards to
prevent a local authority from discontinuing or rationing access to needle
exchange services? Hopefully this won’t arise, but what if something like it did?
One possibility, incidentally, is that the decision could be challenged using the
NHS Constitution. DrugScope has just submitted a response to a consultation on
strengthening the NHS Constitution. But howmany users of drug services (or
staff) would realise the NHS Constitution was relevant to them?
DrugScope’s response to the Department of Health’s consultation on
Strengthening the NHS Constitution
is on the DrugScope website at
www.drugscope.org.uk
Marcus Roberts is director of policy and membership at DrugScope, the
national membership organisation for the drugs field, www.drugscope.org.uk
Is recovery pushing harm
reduction off the drug policy
radar, asks
Marcus Roberts
OFF THE AGENDA?