Beyond Methadone - A VOCAL Report (from a drug workers perspective)
Beyond Methadone – Improving health and empowering patients in opioid treatment programs (A VOCAL Report).
(From a drugs workers perspective).
I currently work for a substance misuse service in the UK providing a range of harm reduction interventions to service users with a range of complex psychosocial problems related to drug and alcohol use. Due to my interest in the area of harm reduction and in particular substitute prescribing I would like to give my perspective on the following report. All of my experience in the field of harm reduction thus far has been in the South of England and therefore I do not presume to generalise my views however I believe some of the points I will make are relevant to drug treatment services within the UK and worldwide.
The Beyond Methadone report was authored and published by VOCAL and Community Development Project of the Urban Justice Center, whom have carried out qualitative research into the service user perspective of 29 Opioid Treatment Programs (OTPs) currently operating in New York. I believe the report covers some very important and interesting areas in regards to OTPs in the US and worldwide. The fact that the study has decided to use a service user perspective is also of great importance, as it is a perspective which many researchers either ignore or are unable to access effectively. Many of the points made within the report are vital in order to improve the experiences of those utilising OTPs now and in the future.
The report is based on 500 survey questionnaires completed by service users receiving treatment from one of 29 OTPs within New York as well as 5 focus group each containing 33 patients, all data was collected between between May and November 2010. From the report methodology it appears those participating were representative of the service user population within New York both in terms of ethnicity, gender and their current/recent social circumstance.
The report firstly highlights 5 issues which were identified within the surveys and focus groups. These are as follows:
Harm reduction and other Medical Interventions.
Hepatitis C Virus.
Patient Rights and Involvement.
Police and Security Harassment.
Harm reduction and other Medical Interventions
The key findings of the research study showed that OTPs in the area of New York are failing to provide basic harm reduction interventions to OTP patients. Shocking statistics such as 1 in 10 people surveyed had overdose within the last 2 years and 1 in 5 had witnessed someone else overdose were revealed and OTPs have been criticised regarding the lack of training/advice/information they provide to patients regarding opiate overdose.
As a harm reduction worker I can understand how these OTPs maybe criticised for not providing this life saving intervention . I agree with the report in the fact that I cannot see any reason why these services cannot provide a basic level of overdose advice/awareness to service users. Basic interventions could include a conversation regarding the risks of poly depressant drug use or lowered opiate tolerance, or a range of information leaflets handed out to those deemed at risk of opiate overdose.
However the report does go one step further in recommending that all OTPs deliver Naloxone administration/overdose training to those at risk. This is an intervention I have personally been involved in delivering, whilst working in South West England I helped facilitate a pilot training scheme regarding Overdose training/Naloxone administration. I personally found the experience incredibly rewarding and believed that we made a real difference to the opiate dependant community in that particular area.
I then moved to another drug service in London where I put forward the idea of delivering Naloxone administration/overdose training to high risk service users. My ideas were praised however there were a number of barriers to carrying out this training. Firstly finances were a problem, the pilots success was partly due to contingency management (where service users received £10 for attending) as well as this money would also be needed to buy a stock of Naloxone administration kits. Even whilst carrying out the previous pilot, the price of Naloxone was steadily increasing and a couple of training sessions had to be cancelled due to manufacturers reported shortages of the drug in the desired 0.4mg/1ml ampoules. Another issue expressed was the accountability issue regarding prescribing Naloxone, who would be responsible if the medication was diverted or used maliciously? Many doctors felt uncomfortable in prescribing a medication where one service user would be administering via IM a medication in an emergency situation. Another factor was that the first service was a voluntary organisation whereas the second was statutory, I believe this made a large difference in terms of accessing funds and having the freedom to develop new ways of working.
By the end of the discussion most of the team felt it would be best to provide information alone (in the form of an overdose booklet and DVD) and emphasise the fact to call an ambulance immediately. I can't say I agreed with this decision and am not saying that the report is wrong to suggest such training. However I can empathise in the fact that as a busy and financially strained OTP it is not always easy to put an “ideal” training package into practice.
The report highlights the lack of needle exchange provision for OTP patients, with three quarters of respondents requesting somewhere to dispose of used needles and the same amount requesting sterile injecting equipment available at their OTP. From my own experience working in OTPs in the UK I can say that needle exchange provisions have been excellent for injecting service users and agree that this is a basic service provision that will reduce the spread of Blood Borne Viruses within this population as well as protecting the health of the general population and saving healthcare services large amounts of money in the process.
Buprenorphine is a relatively new drug on the substitute prescribing scene in comparison to methadone but is widely used in OTPs within the UK and a medication I have witnessed aid service user to achieve stability/recovery. According to this report two thirds of OTP patients had not been given the option of Buprenorphine or received any information. One thing that the report does not point out is that transferring an individual from methadone onto Buprenorphine can be a difficult process due to the risk of precipitating severe opiate withdrawal and possible de-stabilisation. However this does not account for why people have not even been given information/advice on the drug, considering its huge harm-reduction potential as outlined by the report (including a reduction in opiate overdose risk when compared to methadone use) it should be much more widely discussed within this district and offered as an alternative.
Hepatitis C Virus (HCV)
The report outlines the issue of HCV within the injecting drug user population and those attending OTPs. It then goes onto highlight the failings within New York OTPs to provide quick and effective HCV testing and treatment, with more than one in four respondents having never been tested for HCV at their clinic. Just as shocking is the statistic that 50% of respondents reported no knowledge of HCV materials available at their treatment clinic.
The first issue is an area of real concern and something which I am thankful to say working within both a voluntary and statutory lead drug service has always been dealt with effectively and promptly. There are differing views on when/how individuals using drugs or alcohol chaotically can be treated effectively without risking treatment drop out, meaning any subsequent treatment may become less effective in fighting the virus. However the report has highlighted an excellent HCV treatment service for OTPs the Albert Einstein College of Medicine which provides flexible, individualised and skilled treatment to patients. Proving that these barriers to HCV diagnosis and treatment can be overcome.
The second statistic regarding the lack of knowledge on the nature of HCV and its transmission is totally inexcusable and hopefully this excellent report will bring about change to the OTPs in the New York area, within the US and worldwide. Again the treatment services I have personally worked for and harm reduction organisations I have worked alongside throughout the UK appear to invest a lot of time and resources into preventing new cases of HCV and educating those injecting drugs of the risks associated.
The report has highlighted three main areas which respondents have identified as barriers to remaining in treatment effectively. The most common was limited clinic opening hours followed by transportation assistance delays and Medicaid case closures. These missed methadone doses have been linked in the report to higher rates of street methadone/heroin use and other illicit drug use.
From my personal experience I can understand how these OTP patients may have difficulty maintaining contact with a clinic due to these barriers however by working for OTPs myself I also have some criticisms on this part of the report. Whilst working for a voluntary sector drug treatment service I provided outreach services to those living in rural areas, these people did have real difficulty getting to the treatment centre and on many occasions service users would tell me that without the outreach service they would be isolated. On moving to a more urban location with good transport links I felt that maybe patients may find it easier to get to their weekly clinic appointments and nearby pharmacy. Before recent government spending cuts our service would even be able to provide free bus tickets to those who had not yet received benefits (unfortunately this has since stopped) and those who were on benefits could claim the money back. However it became apparent that regularly service users would turn up following closure this would occur even on days when our opening hours were extended into the evening. Whereas other service users (usually those who had achieved some stability on substitute medication) would always be on time and ensure that they collected their methadone doses from the local pharmacy before it closed.
I understand the reports reasoning regarding later opening hours however from my personal experience even when opening hours are extended service users will not always attend on the specified day or before closing. It could be argued that as chaotic drug users these people need flexible and adaptable services that meet their needs, which is true to a certain extent. However I do believe drug treatment services do have limitations to the support they can provide individuals and an element of motivation and responsibility is required on the part of those accessing treatment. In my opinion it is not realistic (or cost effective) to have a drug treatment service open 24 hours a day as a drop in and some could argue that opening and closing hours can help give individuals structure and routine, an important part of integration and recovery.
The closure of the OTP patients Medicaid cases is a separate issue unique to the US and therefore I do not feel able to comment upon this point however the report later goes onto say as part of its 'political context' section that changes are being made to the US healthcare bill which may have a positive impact in regards to this area (see page 24 of report). I am aware from experience in the UK that the current benefit legislation is often complicated and many service users struggle to firstly understand the system and secondly comply with the regular medical reviews and supporting documentation. Many service users have informed me that their money has been stopped due to a number of reasons, on attempting to support them in re-accessing benefits I have found the experience incredibly frustrating and difficult due to the high demand of calls and bureaucracy of the system. I believe that it is unnecessarily difficult for vulnerable people.
The report has put forward a number of recommendations in order to improve service user engagement in treatment most of which are feasible and realistic and are centred around the flexibility of staff at OTPs and collaboration between different services, co-ordinating care in order to encourage a patients continued engagement. However the report also suggest that OTPs exercise maximum flexibility in providing methadone take homes doses when patients qualify. From my experience managing situations where service users need to work (or have other commitments) and require a flexible approach to methadone pick up can be an extremely difficult clinical decision to make. I have often wanted to provide a service user with take away medication however incidents across the UK where children have swallowed methadone and in my own professional career where a minority of service users do not disclose their true social situation (for example in one case having two young children at home), causes great anxiety and can create a cautious approach. These decisions are usually made based on a case by case basis and 'qualifying' factors differ for each individual such as children, substance using peers/partners, risks of diversion, patients other drug/alcohol use, time period and presentation in treatment. I understand what the report is trying to express however it has not acknowledge the complexities such a decision involves.
However as the report mentioned previously Buprenorphine is a much safer alternative to methadone in many respects and therefore a service user on Buprenorphine will be given take away doses more readily than those on methadone. Therefore this transfer of medication has been encouraged on many occasions to service users I have worked with who would like a more flexible pick up (once considerations regarding their current stability and risks of relapse have been taken into account).
Patient Rights and Involvement
The report identifies the importance of patient involvement in treatment services and the positive effect this has on their attitude towards treatment and leads to longer engagement and better treatment outcomes. The report also looks at patient rights, complaints procedures and informed consent presenting the statistic that 7 out of 10 respondents were unaware of their local patient advisory board. A further 50% stated that there was no printed information at their local OTP regarding advocacy services and 66% were not aware of the grievance procedure at their OTP. Another concerning statistic especially from my point of view as a practising substance misuse nurse was that 1 in 7 respondents did not feel their counsellor respected their opinions.
All of the above points are very important and need attention in order to make service users feel empowered and heard, leading to a positive experience as an OTP patient and better outcomes longer term. The recommendations within the report are very relevant and achievable from my perspective such as investing more time into developing good patient advisory committees, publicising patient rights in OTP clinics and training staff accordingly as well as identify optimal case ratios for counsellors so they are able to give service users with time and support they need.
I can say from my experiences that drug treatment services are improving in the area of service user involvement and participation but there is still a long way to go and I support the issues regarding this area that have been highlighted by this report.
Police and Security Harassment.
The final issue discussed within the report is regarding law enforcement in the New York area. 4 out of 10 respondents reported to have been searched by police/security outside of their OTP (however the report does state this does vary according to each site). Rightly so the report has condemned this behaviour on behalf of the police pointing out that this will only discourage service users from accessing treatment. This point brings us back to the authors intention in publishing this report and their wider ideology as an organisation, addressing drug use through a health and safety approach as opposed to a criminal justice approach.
I have personally witnessed community support officers standing near my place of work and have witnessed them question certain patients when leaving the treatment centre. On these occasions our service have spoken with the police requesting that they do not loiter outside of our building. However on occasion the police have been forced to attend due to a minority of service users causing disruption inside and outside of the clinic. Therefore I agree that it is wrong for law enforcement services to target OTPs as a place to search and question individuals, however there are a minority of service users from my experience which have needed law enforcement involvement in order to prevent other service users as well as OTP staff from being verbally and/or physically abused.
A good recommendation from the report is for more dialogue to take place between OTPs, service user representatives and law enforcement. This would allow law enforcement to have a better understanding of what OTPs are trying to acheive and how law enforcement could be causing more problems rather than solving them in certain situations. At my current place of work we have been given the name of a substance misuse/mental health specialist police officer who has received specific training in this area and can be called upon if concerns are raised regarding local law enforcement practices.
Overall I believe this report provides some valuable insights into the service user perspectives of OTPs in New York and can see how nearly all of the issues highlighted affect those accessing drug treatment services worldwide. More research studies of this type are needed in order to encourage more service user involvement in the development of services empowering this often marginalised population.
As you have seen my only criticisms of the report have been that some of their recommendations could be deemed idealistic and no attention has been paid to the funding and staffing issues these OTPs currently face. It is easy to recommend interventions but from experience carrying them out on the ground can be incredibly challenging at times.
I also felt that the report could've enquired into the OTPs practice regarding the psychosocial interventions they provide. Psychosocial interventions such as cognitive behavioural therapy, brief solution focused therapy and motivational interviewing are included within the NICE Guidelines “Drug misuse and dependence – UK guidelines on clinical management”. This was following the view that many OTPs within the UK were focusing too heavily on substitute prescribing and medical interventions alone and needed to take a more holistic approach towards recovery allowing service users to look at every aspect of their life in regards to substance misuse and not just their withdrawal symptoms (which was argued to be rather a short term solution). Research suggests that using these interventions alongside substitute prescribing can improve patient engagement and lead to better outcomes. Collaborative working and the therapeutic relationship were touched upon briefly within the report but again a service users perspective on whether OTPs were achieving this effectively and whether service users felt it was necessary, irrelevant or even patronising would have been a useful insight.
Nevertheless many of the OTPs failings are basic and crucial components of a good harm reduction service and my only hope is that the report will be taken seriously by those with the power to make the real changes required.
To see full report use the following link: