Why are abstinence-based services not promoted in Brighton and Hove?

(Since posting the article below, I have received a very positive response from NHS Sussex and abstinence-based services, including BHT’s Detox Support and Recovery Projects, are to be included on the various websites. This response is much appreciated).

For the last few weeks I have been running a small campaign to try to get abstinence-based services for those with alcohol and drug problems included on websites run by the City Council and NHS Sussex. It has seemed to me to be quite extraordinary that, while harm minimisation services appear prominently, abstinence-based services were ignored.

Clients in BHT’s Recovery Project have consistently said to me that they were either not told about BHT’s abstinence-based services or, in some cases, actively discouraged from seeking abstinence itself.

At recent events on drugs organised by Caroline Lucas MP and Mike Weatherley MP, I asked whether the lack of promotion of abstinence and abstinence-based services was policy or cultural. The only responses I got were from someone who said I was “paranoid” and another who said that I liked to make criticisms of other agencies. Neither is true, certainly not the latter.

As for paranoia, I had a look at the various websites and other publications designed to help those in Brighton and Hove with alcohol and drug problems. BHT’s abstinence-based services, the Detox Support Project and the Recovery Project, were absent in all but one of these sites.

A booklet ‘What next? Your guide to drug treatment and recovery pathways in Brighton and Hove’ lists over 40 services, from harm minimisation services and prescribing services through to where you can get help getting a crisis loan. It includes some BHT services (such as Threshold, our Housing Advice Centre and First Base Day Centre) but it again fails to mention abstinence-based services including the Detox Support Project and the Recovery Project).

No one has yet answered whether the decision (it has to be conscious since it happens so consistently) is cultural or policy. If the former, something needs to be done since people in Brighton and Hove are being denied choice. If policy, who has made this decision and why?

In the last few days the City Council has amended some of its web pages to include the missing services and approach. I am grateful for this but wonder why on the main City Council website these services are posted under ‘Who else can help’ section rather than the main ‘Where to find help locally’ section.

I will continue to make a nuisance of myself until there is a shift in culture or a change in policy!

Reflections on the debates on drugs organised by Caroline Lucas and Mike Weatherley

During September two of our local Members of Parliament, Caroline Lucas (Brighton Pavilion) and Mike Weatherley (Hove), had the courage to organise debates on a major issue facing Brighton and Hove: drugs.  I say courage since drugs is an issue that many politicians will shy away from.

The two events were quite different, one behind closed doors with senior officers from statutory and third sector agencies, the other in public.  I am grateful to both Caroline and Mike for the invitations to speak at both events. 

The topics under discussion ranged from health and social care to decriminalisation and legalisation.  If I may offer one criticism of both events, the subjects under discussion were too wide-ranging.  To do justice to each topic, they should have been considered at different meetings, health and social care at one, decriminalisation and legalisation at another, rather than all issues being discussed at both meetings.

While Caroline and Mike are not often found lining up together, they are both to be applauded for their separate initiatives in addressing the reasons for Brighton and Hove’s high rate of drug-related deaths.  They work together through the All Party Group on Drug Reform.

I remain firmly of the view that there needs to be a move away from a medical approach (as opposed to a health and social care approach) when dealing with drug addiction.

A medical intervention is important in stabilising individuals and then detoxing them quickly and with as little discomfort as possible.  After that there is little need for any medical involvement (unless there is a co-existing yet separate medical condition).  After that social care, housing and self-help interventions should take over aimed at helping clients to become independent and to sustain a drug-free lifestyle.

I am not a supporter of decriminalisation, and a strong opponent of legalisation.  I have always felt that helping addicts achieve and maintain abstinence is the best form of harm minimisation and removes the need for criminal activity.

What the impact will be of the events organised by Caroline Lucas and Mike Weatherley is unknown.  I know what I want to see: all local agencies, and all their staff, championing abstinence, and I hope to hear fewer people writing off the potential of all addicts with comments such as “abstinence is not for everyone”.  My advice to them is it’s not your place to say that.

Championing abstinence is what is needed to tackle the drugs problem in Brighton and Hove

Brighton and Hove has the unenviable record of having the highest rate of drug-related deaths in the country.  The problem of drugs is being addressed at two events being held in the City during September.  I was recently invited to speak at the first event, a ‘Round Table’ discussion organised by the MP for Brighton Pavilion, Caroline Lucas.  I will also be speaking at the second event, open to the public, which is being organised by the MP for Hove, Mike Weatherley.  Details of this event can be found here.

Here is the text of my contribution to the Round Table discussion:

BHT’s treatment programmes and the benefits of an abstinence based approach

BHT services support chaotic drug users, many with a history of street homelessness, through harm minimisation interventions (such as the needle exchange operating at the Phase 1 Project), and we champion abstinence through our Detox Support Project and our residential rehab, the Recovery Project.

However, nothing we do, none of the services we offer, provides the answer we are seeking today. But each is a means to an end – and that end is normal living free from drug dependency.

If clients move from chaotic use to using a needle exchange, that’s great but we have to ask “what next?” If they stabilise their drug use by going on a maintenance script.  We again must ask “what next?” If they detox, at BHT we ask what next?  If they go into residential rehab, we continue to ask “what next?”

I believe all interventions have a place in the recovery process.  However, we must constantly ask what is best for our clients. And we must actively help clients move through to the next stage of recovery. 

If any service does not move its clients through to the next stage at the earliest possible opportunity, not months and years into an intervention but within days and weeks, that service is selling its clients short.

I fear that there has been, for over two decades, a government-led lack of ambition on behalf of drug users. It has resulted in far too few clients moving from dependency into abstinence, and too many people have been left with one foot still in drug-using culture.

In Brighton andHove, the promotion of abstinence has been largely ignored.  Other than CRI’s St Thomas Fund and BHT’s Addiction Services, no funded service has abstinence as its primary focus.

This has resulted, inevitably, in a year on year increase in the number of addicts, either using street drugs or those on maintenance scripts (and they are probably topping up on street drugs).

Why are we failing to get beyond harm minimisation, through abstinence and into stable housing, education, training and employment?  I can think of three possible reasons:

Skills: Are our workers as skilled as they should be?  Do we need to review our training so that they can become more effective in helping clients achieve abstinence?

Attitude: Too many in the drugs field find too many reasons why an abstinence approach is not right for a particular client or as they will say, the client is not ready.  There used to be a programme locally called the Abstinent Programme but meaning abstinence from street drugs. There is a lack of ambition.

Policy: Medicated treatment as an outcome has been the policy of successive governments and also at a local commissioning level.  We now have a perfect opportunity to change that.  The Coalition Government’s strategy is for a ‘treatment revolution’ and that abstinence should be championed.  I welcome this wholeheartedly, although I have doubts about the approach it is taking to payment by results.

What are the consequences of us not championing an abstinence approach in all services:

• Ever-increasing numbers of drug users
• Ongoing social dysfunction
• More and more children needing to be looked after by the local authority at huge cost
• Increased domestic violence
• An inevitable increase in drug-related deaths
• An increase in crime
• Increase demands on health services
• Damage to the reputation of the City and consequentially its economic health.

A further consequence of not changing is that in ten years time we, or our successors, will be sitting in a room like this asking what can be done about the drug problem in the City and the unacceptably high drug-related death rate.

So, we should start by acknowledging that clients want abstinence.  Locally, just 9% leave drug services drug free, compared to a national average of 14%.

BHT originally adopted an abstinence approach directly in response to demands from clients. Over the years this message from clients has become stronger, and those who make it into our service offer the criticism that they were either not made aware of our service, or abstinence was never presented as an option.  In fact, it is not uncommon for clients to say they were actively discouraged from seeking abstinence.

A monitoring questionnaire used to ask clients what they wanted to achieve when approaching a drug service.  In year 1 the answer, in 83% of cases, was abstinence.  The question was discontinued.

Unless we collectively overcome this lack of ambition for our clients, unless we seek the best outcome for them (and at the earliest opportunity), and until we stop justifying drug use as a “life style choice”, we will continue to fail our clients and our City.

Finally, a question: What would you want for your son or your daughter if they had an addiction? Ongoing maintenance or a clear move towards a drug-free life?  We should also want the best for our clients.

The ambition of abstinence is key to tackling drug addiction

This is the text of an article I wrote that first appeared in the Brighton Argus on 21st June 2011 and in Drink and Drug News in July 2011:

In the last week I bumped into two former clients of Brighton Housing Trust’s Recovery Project. The project offers an abstinence based programme which provides a route to life without use of illegal drugs or prescribed substitutes.

Rob (not his real name) is just finishing his final exams at Sussex University. He looked well although stressed and tired due to lack of sleep. The next day I saw Rachel (again not her real name) who spoke about how much she was loving her new job – she had recently been promoted to become a manager within her organisation. I remember her 15 years ago when many would have written her off as another “hopeless junkie”.

One had left the Project four years ago, the other more than a decade ago. They have remained abstinent and have turned their aspirations into reality. Both are happy. Both are an inspiration to me and others, showing that recovery from addiction is possible.

In the same week I read the comments of two leaders in the City with whom I often agree, Caroline Lucas MP, and the head of Brighton police, Chief Superintendent Graham Bartlett, who have called for the decriminalisation of drugs and a harm-minimisation, health-based response. They said that “the war on drugs” has failed, that a new approach is needed that looks at the problem from a health perspective, with more prescribing to reduce crime and social dysfunction.

Like them I am deeply concerned about the high death rate of addicts in Brighton and Hove. However, I was frankly depressed by their proposals since (apart from the call for formal decriminalisation of private use) they are simply advocating a view which has dominated government policy since at least 1997. It is a policy that has failed. This policy has seen ever-increasing numbers maintained in drug use, with spiralling costs to addicted individuals and the wider community that cannot be sustained in ethical or economic terms.

The coalition government has signalled a fundamental change in approach, although this has yet to be translated on the ground. It says it wants to change the way drug addiction is tackled, with more people with problems diverted away from prison and into treatment as part of what it calls a “rehabilitation revolution”. Its strategy involves “championing abstinence” and the Department of Health said its aim is to get users “off drugs for good”.  I support all of this.

The Department says the current annual cost of maintaining treatment for 320,000 problem drug users is made up of £1.7bn in benefits, £1.2bn for looking after their children and £730m for prescribing the heroin substitute methadone.

A key issue is one of ambition or rather what can now be seen, in hindsight, as a poverty of ambition. Do we think that it is acceptable to tolerate the £3.6bn now spent on treating users with drug substitutes like methadone and keeping them on benefits each year, not to mention the wasted potential of 320,000 (a conservative estimate) addicts who are maintained in their drug use. Is it acceptable that addicts who wish to be abstinent have for many years now been all too often either denied the detoxification facilities they need or have been actively encouraged to use heroin substitutes?

It is a simple matter of logic that things cannot improve if much of what we do is to maintain people in their addiction. Clients in the Recovery Project testify that, before entering our abstinence programme and when on maintenance scripts, they ‘topped up’ with street drugs. There is also an active market in prescribed drugs which are sold on by addicts supposedly ‘in recovery’. Those addicted in this way may not use or commit crime at the same rate, but they are certainly still stuck in the drug using culture and often acting illegally and destructively.

It is surely ethical that addicted people should be helped to achieve genuine abstinence since it is only when abstinence is achieved that healthy relationships, safe parenting, genuinely secure housing, education, training and employment become viable options.

I fully support the call made by the think tank, the Centre for Policy Studies (CPS), for “a real transfer of power from large distant organisations to small innovative providers” for

rehabilitation.  I agree that small units such as the Recovery Project have a better chance of getting addicts off drugs completely, not least because they tend to involve abstinent users in the planning and delivery of services.

Kathy Gyngell, from the CPS, said prescribing methadone to addicts delays their recovery. “The state is subsidising people to be any number of years on methadone, which has turned out not to be a cheap option and will only subsidise the tiniest proportion – 2% – to go into a rehabilitation unit that would actually free them from dependency and allow them to live their life.”

The CPS states “There is one simple measure of success: that of six months abstinence from drugs.” As the CEO of an organisation which offers both harm minimisation services and genuinely abstinence-based treatment, I am ambitious on behalf of our clients. I maintain that 6 months abstinence is readily achievable and would go a step further. Treatment providers should be judged on whether the client is genuinely abstinent – from all mood-altering drugs – six months after finishing treatment.

 Recovery from addiction is possible. Those of us involved in policy making, commissioning services and delivering treatment for addicts have an ethical duty to offer safe care to using addicts, but to ensure that treatment leads, in each and every case, to abstinence. Too many lives depend on it.

Reflections on 25 Years at BHT

I started working for BHT 25 years ago today. I hope you will forgive me for posting something more lengthy than usual: my reflections on BHT, what we are here to do, and the need to increase the pace and scale of change for the benefit of our clients.

BHT’s Mission (“combating homelessness, creating opportunities, promoting change”) doesn’t go back quite 25 years, but it continues to provide a neat summary of what we are about. Or does it? We have recently reviewed the Mission and what we mean by it, and fresh challenges have emerged, not least because of the economic and social policy changes we are facing.

In his speech in Downing Street, immediately after being asked to form a government, David Cameron said he aimed to “help build a more responsible society here in Britain… those who can should and those who can’t, we will always help. I want to make sure that my government always looks after the elderly, the frail, the poorest in our country”.

Since that speech, government ministers have emphasised the message that individuals ‘who can’ are expected to take responsibility for addressing their situation and for moving from dependency on benefits and into work. Measures are being put in place to put pressure on claimants to seek work. The change to housing benefit eligibility is an obvious and high profile measure that the government seems determined to implement in spite of wide-spread opposition.

There are some proposals which I, personally, welcome and endorse. The government is determination to tackle drug problems. Those with drug problems will have to engage in treatment or they will lose their benefit entitlement. I have some serious concerns about this, but not so the treatment model that Ministers are promoting. They have instructed the National Treatment Agency to “champion abstinence”, a 180 degree change from that of the previous government where stabilisation and harm minimisation was the objective. This is a policy change that I, personally, have advocated for more than a decade and one which I warmly welcome.

I believe that if we are to see lasting change for those with addictions, achieving abstinence is not the end goal, it is merely the starting point for a transition to normal living.

The services provided by BHT remain as relevant as ever, and the need is likely to increase. What each service seeks to achieve will need to be reviewed, partly in light of the changing social policy and financial environment, but mainly because regular reviews are the right thing to do.

BHT must retain and enhance its reputation of ‘doing difficult’, working with homeless men and women, including those with complex needs, and we must retain our ability to work with people where they are at. But we must also ensure that by emphasising the vulnerabilities and problems experienced by some of our clients, we do not ‘ghettoise’ all clients. Many of our clients are in housing need simply because of the lack of affordable housing. As my colleague John Holmström continually reminds me, we must put housing back into homelessness!

Combating Homelessness

BHT recognises that there is a genuine shortage of affordable and social housing and that alternate provision is required to meet housing needs of our clients through the private rented sector. Securing social housing for our core client group is becoming a less achievable outcome and will remain so, at least during the lifetime of this parliament. Councils are using new legal freedoms to give people with a job an advantage over unemployed people when it comes to gaining social housing. Already Manchester, Rochdale, Newcastle, Barnet, Uttlesford and Westminster (who between them manage almost 86,000 homes) are amongst those who plan to give people in work or training priority in the allocation of social housing.

BHT’s current policy is to campaign for greater provision of social housing. While we will continue to argue the case for public investment into bricks and mortar, in the current environment our clients are likely to be best served by increasing access to the private rented sector. In doing so we will need to be upfront and honest with our clients that social housing is not likely to provide a solution to their housing need. We need to ensure that they are focused on preparing themselves for housing in the private rented sector and all that that entails. If our clients are able to secure social housing, that will be a bonus.

Creating Opportunities

BHT creates opportunities and circumstances that will increase the potential for clients to be housed, undertake training and education, and secure employment since poverty is a major reason for homelessness and ill health. In the current environment, our clients will not thrive if they opt out of engaging in rehabilitation, training and employment opportunities. Our staff must ensure they motivate clients to actively engage with this approach, and they should spell out the consequences of ‘opting out’ in terms of housing opportunities and future welfare benefit entitlement.

We must ask if we trap people with their labels, get people identified by their problem. Do we inadvertently create ‘ghettos’ by reinforcing the problem by providing services that might suggest that mainstream services are for others? Do we have the right attitudes, culture and expertise to ensure that clients have ambitions, and that those ambitions are meaningful and achievable? And do we nurture hope and aspirations within our clients?

On the whole I think we are doing ok and in some areas very well, but there are some areas and individuals who may argue that clients have a right, for example, not to address their alcohol or drug problem, who will excuse a failure of a resident to pay rent, or who will focus on a ‘counselling approach’ at the expense of housing, training and employment solutions. I believe that should such attitudes or work practices exist, they need to change.

Promoting Change

‘Combating homelessness’ and ‘creating opportunities’ are fairly straightforward concepts. Not necessarily so with ‘promoting change’. Most, if not all, staff would support the concept of ‘change’, and BHT does some inspirational work in facilitating change for our clients, but we now need to go to the next level by being clear exactly what “promoting change” means. There may be a few who would qualify a commitment to change with “only if that is what the client wants” or “but clients have the right not to change”. What the client wants or does not want should not be the defining factor for us. We have a moral duty to work in the best interest of the client and clients as a whole. True advocacy requires the advocate to spell out what is best; it is not merely giving a voice to a client’s wishes regardless of how unachievable or non-sustainable such wishes are.

I believe that the pace and scale of change can and must be increased, firstly, because it is right for our clients and, secondly, because of the prevailing economic and social policy imperatives that have emerged following the 2010 general election. There should be an expectation that staff ‘drive’ change. The concept ‘promoting change’ is not passive. In doing so we must equip clients to manage their problems and to sustain progress made.

Whatever our views are of the approach of the Coalition Government, those “who can” who remain dependent on welfare benefits and state support will find fewer opportunities (accommodation, benefits, etc.) and a more ‘coercive’ approach from government. We must prepare our clients for this reality. There needs to be a sense of urgency about this agenda.

During the remainder of 2010/11, we need to review our approach to ‘change’, its scale and pace, and put in place new policies and approaches should they be required.

 There are a number of issues that will need to be explored further. For example: 

• How can we understand the difference between ‘can’t change’ and ‘won’t change’, and how we should continue to work with clients in each group? We don’t want to create new classes of excluded men and women.
• How should we position ourselves regarding choices and consequences? For example, with rents, should we only support move on if someone has no arrears, or no arrears for 3 or 6 months, etc.? This is a real client-centred approach where we treat them in the real world, not in some cotton-wool world.
• What can we expect, even demand, from clients when considering what is “for the greater good”?

How we do this must be left with individual services, but I am giving out a clear message that we need to increase the pace and scale of change. It is a message that should be welcomed by most, not least because the greater the change, and the sooner it happens, can only be good for our clients. BHT, its staff and supporters have a lot to be proud of, and we can be excited about the difference we will be making to the lives of our clients for the next 25 years.