The legitimacy of addiction treatment in a world of smart people

Successes and failures in treatment of substance abuse: Treatment system perspectives and lessons from the European continent

Objective:

The article offers an inventory of controversial basic issues related to treatment responses and their sociocultural political context, highlighting policy failures and successes, with a focus on Europe. As a reference point for this assessment, serves a conceptual framework of an “ideal type of treatment system”, which is built upon the following normative assumptions: the objective of harm minimisation or preventing substance-use-related consequences, evidence-based decision making, securing equity and accessibility also from a user perspective as well as efficiency in terms of the diversity and choice of treatment options.

Method:

Five major issues of addiction treatment systems, as identified and exemplified by an expert survey among 14 countries conducted in 2014, served as a reference for discussing fundamental gaps between an assumed ideal type of treatment system and the treatment response in practice: (1) Resistance to change, consensus building and innovation, (2) Political influence and target group bias beyond evidence, (3) Assumptions about rationality and universal evidence, (4) Myths of addiction and ethical deficits and (5) The treatment gap and user perspectives.

Results/conclusions:

Recommendations relevant for politicians, system planners, and clinicians are formulated for each of the five issues, specifically focusing on embeddedness of treatment systems in macro-societal conditions, the abstinence paradigm and outcome diversity, ethnocentric biases of the “evidence credo”, learning from self-change as the major road to recovery, and questioning implicit conceptions of the “addict as a human being”. Furthermore, it is concluded that theories regarding the diffusion of innovation and knowledge exchange can inform future research.

Research report

Processes of change during and after drug treatment, What factors are described by clients as important to initiate and maintain positive changes?

Aims

The aim is to describe and analyze how clients recovered from alcohol or drug abuse perceive change in connection with treatment interventions. The specific questions are: What factors are described as important to 1) initiate a process of change? 2) avoid returning to abuse?

Design

40 clients were interviewed according to a brief interview guide. The analysis resulted in models with factors that the clients considered important for initiating and maintaining positive changes.

Results

The result suggests that a pattern is emerging in the process of change. Although the clients often describe common factors as important, the variation of timing and severity for different factors makes the individual story unique.

Conclusions

The variation of timing and severity for different factors implies that it is very difficult to predict when a factor is important or not. This underlines the importance of treatment systems with a structure and a flexibility that enables supporting factors to be used when they are of importance for the individual client.

Research Report

Social service and addiction treatment: rehabilitation or harm reduction?

AIM

This paper aims to depict and analyze how professionals in Swedish social services legitimize two ideologically controversial help interventions, methadone maintenance and coercive treatment. Should addiction treatment primarily rehabilitate clients, or should it be a short-term measure for harm reduction? This question has been less and less discussed in Sweden during the past few years, as it has been accepted that all help should be based on science, not ideology – irrespective of it being aimed at harm reduction or rehabilitation. However, there is a lack of research regarding how crucial players in addiction treatment relate to this development, especially when applied on socially vulnerable clients.

MATERIAL & METHOD

The empirical material consists of 33 qualitative interviews with social workers from Stockholm and its surrounding area. The interviews are analyzed through discourse analysis.

RESULT

When describing their work, the respondents’ discourse assumed and advocated progress in client case management.

CONCLUSION

By emphasizing concepts such as lifestyle change, client motivation, psychosocial support and aftercare the social workers could construct the two forms of treatment as less ideologically extreme, but also as undoubtedly aligned with the political goal of rehabilitation.

Limits of Evidence – the Case of Psychosocial Interventions in a Swedish Review of Maintenance Treatment Research

In Sweden, maintenance treatment (MT) with methadone has been a controversial exception to drug-free treatment. However, efficacy, prescription control and the provision of simultaneous psychosocial treatment (PST) have provided MT with political legitimacy. This view, notably stressing that PST is an important complement to medication, was presented in central Swedish policy documents that paved the way for less strict MT regulations in 2005.

Aim

The present study aims to analyse how the various stakeholders involved in this policy process described and evaluated the efficacy and legitimacy of PST within the framework of the MT discussion.

Data & Method

The data consists of a document authored by a state agency (a preliminary review of MT research) and various stakeholders' written commentaries on it. different representations of PST (so-called constructions) were coded thematically and analysed using discourse analytical concepts.

Results

The results show that stakeholders' constructions of PST draw on different discourses related to the governance of Swedish opiate addiction treatment. Four constructions were identified, PST as: “mere complement” (narrow empirical discourse); “underrated intervention” (practitioner discourse); “preferred intervention” (ideological discourse) and “complex intervention” (antireductionist discourse). The study illustrates how the narrow empirical discourse's construction of PST as a mere complement was challenged by the three other discourses, but shows that the former remained the dominant influence on subsequent MT regulations. It also highlights that references to beliefs and alleged facts are intertwined in stakeholders' rhetorical efforts to assign meaning to PST. This suggests that science and ideology are interrelated in policy discussions on opiate addiction treatment, and that firm conclusions about the value of help interventions rely as much on scientific evidence as on strategic argumentation.

Advancing recovery: implementing evidence-based treatment for substance use disorders at the systems level

OBJECTIVE

A multisite evaluation examined the process and outcomes of Advancing Recovery, a Robert Wood Johnson Foundation initiative to overcome barriers to implementing evidence-based treatments within alcohol and drug treatment systems.

METHOD

We report findings from a 3-year, mixed-method study of how treatment systems promoted two evidence-based practices: medication-assisted treatment and continuing care management. We compared outcomes and implementation strategies across 12 state/county agencies responsible for alcohol and drug treatment and their selected treatment centers. Each partnership received 2 years of financial and technical support to increase adoption of evidence-based treatments.

RESULTS

Partnerships flexibly applied the Advancing Recovery model to promote the adoption of evidence-based treatments. Most sites achieved a measurable increase in the numbers of patients served with evidence-based practices, up from a baseline of virtually no use. Rates of adopting medication-based treatments were higher than those for continuing care management. Partnerships used a menu of top-down and bottom-up strategies that varied in specifics across sites but shared a general process of incremental testing and piecemeal adaptation.

CONCLUSIONS

Supported partnerships between providers and policymakers can achieve wider adoption of evidence-based treatment practices. Systems change unfolds through a trial-and-error process of adaptation and political learning that is unique to each treatment system. This leads to considerable state and local variation in implementation strategies and outcomes.

Continuities and changes in self-change research

AIMS

A substantial literature demonstrates that natural recoveries from substance use disorders not only occur but are a common pathway to recovery. This article reviews selectively and comments on the current state-of-the-art in natural recovery research.

METHODS

Basic concepts in natural recovery research are presented, and topical and methodological trends and changes in self-change research over time are discussed.

CONCLUSIONS

Although considerable progress has occurred in natural recovery research, several topics deserving of further research are identified, and implications for policy practice are discussed.

Transforming administrative and clinical practice in a public behavioral health system: an ethnographic assessment of the context of change

In July 2005, New Mexico placed all publicly funded behavioral health services under the management of one private corporation. This reform emphasized the provision of evidence-based, culturally competent services. Methods. Participant observation and semi-structured interviews with 189 administrators, staff, and providers were carried out in 14 behavioral health safety-net institutions (SNIs) during the transition period. Results. New administrative requirements led to substantial paperwork demands, payment problems, and financial stress within SNIs. Personnel at the SNIs often lacked knowledge about and training in evidence-based practices and culturally competent care, and viewed the costs of delivering such services as prohibitive. Discussion. Policymakers must account for the challenges that SNIs face as the reform continues to unfold. The financial stability of SNIs is of critical importance. Efforts are needed to increase training and development opportunities in evidence-based care and cultural competency; SNIs typically lack resources to pursue these opportunities on their own.

Challenges in providing drug user treatment services in Russia: providers' views

The estimated number of opiate users in Russia is 2,000,000 and heroin consumption is continuing to increase. The Russian government is discussing the initiation of compulsory treatment to bring illegal drug users to the treatment services. At the same time, there is no access to the evidence-based treatment for opiate addiction such as methadone and buprenorphine maintenance programs. Qualitative interviews were conducted with drug user treatment service providers (N = 35) in Barnaul, Volgograd, and Yekaterinburg, Russia, in 2003-2004 to examine their views on drug user treatment services in Russia. The framework approach was used in data collection and analysis. Study participants identified major challenges in service provision for drug using population, including lack of resources, rehabilitation programs, and social support. It also depicted ambivalent attitudes toward compulsory treatment and clients' registration. The Russian drug user treatment system desperately needs resources allocation to provide quality care and diversify in its services in order to achieve long-term recovery. At this stage, it seems unreasonable to initiate compulsory treatment as is advocated by some government officials.