Treatment in England: positive, interesting and alarming

December 5, 2020
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Public Health England (PHE) recently published their summary of what’s going on in substance use disorder treatment in England over 2019-20. Despite the shared culture and proximity of Scotland and England, there’s been a significant divergence in drug and alcohol policy and treatment delivery over the years.

We’ve not been good as we might have been in Scotland at capturing the detail and outcomes of treatment episodes across both drug and alcohol interventions, though that’s about to improve with the introduction of a new monitoring system here.

We still have a strong network of addiction specialists working in the NHS in Scotland while this seems to have been eroded in England and many commentators have highlighted reduced funding south of the border. Having said that, comparisons are difficult and of course we have a much higher drug-related death rate in Scotland.

So, what’s going on in England? The numbers entering treatment are pretty steady compared to last year, at over 132,000, more than half for opiate use disorder. There was evidence over time of a stabilisation of the numbers of people entering treatment after past falls. Sadly, there was a 6% increase in deaths of opiate users in treatment since the previous year. Overall, the number of people in treatment totalled over 270,000.

After opioids, the next biggest group was those seeking help for alcohol use disorder (28%). People seeking help for cocaine (powder and crack) was up, which continues a trend, with crack problem presentations increasing much faster than powder cocaine. Problematic ketamine use seems to be up too, increasing 19% in a year, though the numbers are still small.

Something positive

Of the 118,000 people who left treatment, it is reported that almost half left ‘having successfully completed their treatment, free from dependence’. That suggests that a lot of people met their treatment goals and is encouraging.

Something interesting

Here’s something interesting – 58% of those starting treatment were smokers. That’s much lower than I expected, though still about three to four times the rate in the general population. Sadly, given that 50% of smokers will die of causes relating to that addiction, only 3% were offered interventions to quit.

Something disappointing

According to the European Monitoring Centre for Drugs and Drug Addiction’s 2014 report on Residential Treatment, 11% of total treatment episodes on average across 20 European countries are for residential treatment. In Scotland in 2019-20, we estimate it was roughly 4-5% percent. In England, according to PHE it is 2%. This is down 41% over five years. 

Something alarming

Of those clients/patients leaving treatment, a third of patients left without completing.  For those in the opiate group who left, almost three quarters left without successful completion, which is alarming given the risks around relapse.

For comparison, 59% of the alcohol-only group successfully completed. It would be good to understand what factors are influencing the high drop out rate and what we need to do to get better at holding on to people in the treatment system.

Something missing

On page 37 of the UK Government’s 2017 Drug Strategy there is a commitment: 

We will support local partners to measure outcomes from key processes which promote recovery, including: the proportion of clients facilitated to access mutual aid or peer support. 

UK Government

This is great, as is the PHE toolkit on mutual aid. Connecting to mutual aid is consistently associated with improved outcomes. I’d love to see a similar commitment in Scotland.

I was looking to see how many of the new treatment episodes captured this statistic – the proportion of clients who got plugged in to mutual aid. I couldn’t find a single mention of mutual aid or peer support in the report. That’s something missing which could also be used as a proxy measure of quality for services.

Something reflective

As I’ve been writing I’ve challenged myself on my own practice in each of these areas and I’ve thought about what these statistics might have to teach us in Scotland. I’d like us to do better here too with retention in treatment, smoking cessation, connection to mutual aid/peer support and better access to residential rehab.

I hope you’ll agree, there’s not too much to argue with there.

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