What would an evidence based drug policy be like?
BMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g7493 (Published 09 December 2014) Cite this as: BMJ 2014;349:g7493
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The recent call by Singleton and Strang for an evidence-infused drug policy [1] does not substantially differ from other similar evidence-based pleas, a leitmotiv that has become the catch-phrase of the drug policy field [2]. Moreover, when they mention the conditions required for their approach success (e.g., openness to and seeking of evidence by politicians, policy makers and practitioners; open-minded engagement from the public and the media), they do not address the processes and strategies leading to such prerequisites.
Initiatives for surmounting blatant divergences between rhetoric of evidence-based-policy and reality of drug policies seem to be dismissed as non-existent or not relevant. A non idle or futile first step to ameliorate, at least partially, such dissociation must be to acknowledge that evidence is but one input in drug policy-making (i.e., multiple non-evidentiary influences must be accommodated). In this regard, some authors have emphasized that understanding the entanglement of the policing context and the drug policy-making process can help researchers to maximize the uptake of their work [3, 4].
The implementation of successful experiences from social-epidemiological knowledge translation literature [5] and from the research on use of social-science knowledge in public policy [6] is also highly recommended in the drug policy-making arena. Several of these non-conventional knowledge-translation approaches, together with those tailored specifically for the addiction field (e.g., addiction science advocacy [7]), will surely play a significant role in advancing the development of – quoting Ritter and Bammer’s words [3] – an evidence-informed drug policy.
References
[1] Singleton N, Strang J. What would an evidence based drug policy be like? BMJ 2014;349:g7493.
[2] Lancaster K. Social construction and the evidence-based drug policy endeavour. Int J Drug Policy 2014;25:948-51.
[3] Ritter A, Bammer G. Models of policy-making and their relevance for drug research. Drug Alcohol Rev 2010;29:352-7.
[4] Ritter A, Lancaster K. Illicit drugs, policing and the evidence-based policy paradigm. Evid Policy 2013;9:452-72.
[5] Murphy K, Fafard P. Knowledge translation and social epidemiology: Taking power, politics and values seriously. In O’Campo P, Dunn JR, eds. Rethinking social epidemiology: Towards a science of change. Springer, 2012. p. 267-83.
[6] Prewitt K, Schwandt TA, Straf ML, eds. Using science as evidence in public policy. National Academies Press, 2012.
[7] Polcin D. Addiction science advocacy: Mobilizing political support to influence public policy. Int J Drug Policy 2014;25:329-31.
Competing interests: No competing interests
Evidence-informed decision-making and evidence-informed public health requires a mix of knowledge – contextual, experiential, and scientific evidence all have something to contribute. Using a knowledge-into-action approach as an improvement process recognises the need to generate new knowledge, manage and translate this through review, critical appraisal and synthesis, and then apply it in order to determine effective policy and practice.
Developments to consider problem drug use from a public health perspective are informing current debates around drug policy. Championing the reduction of harms and a recovery agenda appropriately allows for this. For example, work in Scotland has focused on defining and attaining positive health and social outcomes for individuals with a set of core outcomes and indicators agreed at community planning level[1] . Furthermore, an evidence-informed Outcomes Framework for Problem Drug Use has recently been published[2] . In illustrating the pathways to achieving positive outcomes the framework outlines the desired direction of travel and available evidence of effective interventions with policy and practice notes relevant to Scotland. Crucially, the framework is not a definitive or prescriptive account of problem drug use, but is offered as a planning resource that can be adapted and reviewed according to local circumstance and needs assessment. It is hoped that where evidence may be lacking this can foster innovation and evaluation in order to contribute to the evidence base, share learning and advance knowledge of appropriate effective interventions.
Consistent with Singleton & Strang’s reflections (BMJ 2014:349:g7493) of the need for a policy-making environment akin to that of a ‘learning organisation’ it is intended that the outcomes framework supports and facilitates the generation, management, and utilisation of knowledge by decision-makers in order to infuse policy with evidence.
[1] see the Scottish Government website http://www.scotland.gov.uk/Topics/Health/Services/Alcohol/treatment/Part...
[2] available online
http://www.healthscotland.com/scotlands-health/evaluation/planning/probl...
Competing interests: No competing interests
I realise that this debate has been more about health versus criminal justice as the driver for substance misuse policy - but I would like to look at it in a deeper more fundamental level than the high level policy for a moment.
In practical terms, at the level of service provision in England, the only game in town appears to be whatever the commissioners say it is. "What works" is in effect being ignored. This is my understanding of the current situation, and this is why:
As we know, substance misuse (SM) services are now commissioned by Local Authorities (LAs) - not Clinical Commissioning Groups. We also know that LAs don't have enough money and are cutting funding to SM services - regardless of any evidence of overall benefit to the economy that we know investment in treatment produces.
Public Health England (PHE) - who is responsible for this commissioning, do not appear to have any power to stop this degradation of funding (sometimes by up to a third in mid contract). However, there seems to be a modest sum of money that has recently identified by PHE for a pilot scheme - which appears to be a small step in the right direction. From the PHE web site:
"A further £5 million of funding has also been announced as part of the Health Premium Incentive Scheme (HPIS). The scheme is designed to reward local authorities that make improvements to their localities public health by providing cash incentives. Under the scheme, which will be piloted during 2015 and 2016, local authorities will be rewarded for meeting one mandatory national public health target, related to improving drug and alcohol services, and one local target of their choice."
Detail appears to be lacking at the moment - and we could speculate about how much of that money will actually end up supporting local drug and alcohol services.
In the meantime, the focus that commissioners have, appears to revolve around metrics such as "successful completions" rather that any actual measure of the quality of service received by individuals. This may be being driven by the "recovery" movement - which has seemed to have led to recovery being interpreted by some in such a way as "the only good treatment outcome is stopping any prescribed substitute medication".
The consequence of this seems to be an overt or covert pressure on service users to "get off their script" - possibly regardless of other gains that are being made such as health, housing, no criminal activity etc. This pressure is also present on the workers and prescribers - despite evidence, guidelines and indeed Professor Strang's own recent report suggesting that any attempt at time limited or premature stopping of scripts can be dangerously counterproductive. However, any harm reduction statistics (drug related death rates, Hep C infection etc) do not seem to be of as much interest these days in terms of contracts and funding. Indeed, recent figures seem to show a rise in Heroin related deaths - which had previously been falling.
Unfortunately, big providers in the field appear to be going along with commissioning requirements without engaging in robust and informed debate about what a good service may look like. (If this is not the case then I would be very happy to hear of the ways that commissioners have been helped to change their tender specifications, and I will gladly stand corrected). Small providers just do not seem to have the clout to compete and their flexibility, local knowledge and skilled teams built over years are often lost to treatment services. Of course, some may work for a new provider, but the world of the big organisation - which has often rapidly expanded and is working hard to manage this - is not the same as the smaller local set up. The larger the organisation becomes, the danger is that it becomes more prescriptive and less flexible for individuals. This is often not appropriate in the complex and often difficult world that substance misusers and their workers inhabit.
I am not saying that services in the past could not have been improved - by no means - there have been many things that have needed to change. But the way to do this is not to focus on simple outcome numbers, but to focus on the quality of the treatment and individual receives.
My contention is that what is needed in any professional/service user interaction - and by extension in a whole service, is the concept of competent compassion. If one or the other of these is missing or weak, then treatment (of whatever modality) is likely to be at best ineffective and at worst dangerous.
These are the fundamental things that a service user wants and needs. After all, that is what we would want if we saw a doctor for example - they need to be competent and compassionate. That is also the way we would want our family members to be treated as well. I believe that this has been lost sight of in the current debates on NHS v private v CIC v charity providers, and recovery v harm reduction, crimilisation v decriminalisation etc.
We need to get back to the quality of treatment an individual gets - this used to be the basis of good medical training (for example) - and it still is. However, these other factors (mainly financial and the competition to win and retain tenders) mean that we are in danger of losing sight of what is fundamentally important and should underpin everything that we as professionals do.
Further discussion of this is at www.competentcompassion.org.uk where you can contact me and let me know what you think.
My intention is not to be overly negative and critical of anyone or any organisation in particular, but I believe that now is the time we have to stand up as professionals and get back to the most important principle - that we want to do the best for the person in front of us that we can.
Whatever the "evidence based drug policy" turns out to be - the foundation should be competent compassion, and we should be leading the call to make sure that it happens.
Competing interests: No competing interests
My answer to this question is no one knows. Addiction is fact of life and life is a journey directed by both science and politics and reliance on one to the exclusion of the other is usually unhelpful.
William Osler said "the desire to take medicine is perhaps the greatest feature which distinguishes man from animals." This may be unfair as if and when animals have access to mind altering substances they tend to overindulge like Rudolph the red nosed reindeer and magic mushrooms. It has been said that primitive societies which had not yet made the connection between sexual intercourse and procreation were familiar with that between taking alcohol and intoxication. Maybe it's in the genes?
Experience as a GP confirms that chronic use of mind altering substances does not lead to happiness or longevity. It also confirms that individuals who abuse drugs including alcohol usually prefer unfettered access to their preferred tipple to cure. Its hard enough to help patients who wish to be cured. If they prefer intoxication it is impossible though many seek medical help to deal with the consequences of their condition. Perhaps instead of cure we should consider a form of terminal care in some cases?
As ever an ounce of prevention is worth a pound of cure. By the time addiction sets in its a bit late to muster medical muscle to counter it. Perhaps we should seek to "immunise " against the risks of addiction. Research would be needed to establish what appropriate "vaccines" might be and how best to use them. These might include optimal child rearing in stable social settings and access to positive role models. This is not a quick fix!
The fact that addiction to narcotics often begins in prison is not in itself a reason not to incarcerate those who break the law but a stimulus to better control of the prison environment. Laws exist to protect individuals and societies from harm and in the main they do this. Humans are social creatures and cannot be allowed complete freedom to do whatever they want at all times.
I believe that to treat substance abuse as a primary medical condition, the following should be in place.
A working definition of the "disease". Not every person who swallows a tranquilliser, takes a drink or smokes a joint is "ill".
Careful study of the natural history of various forms of substance abuse. Some may not be as harmful as was thought.
Scientific research similar to drug trials to establish what forms of treatment in which circumstances have a realistic probability of working.
If these cannot be established I submit it is unrealistic and unhelpful to consider addiction a disease although it leads to multiple serious medical conditions. This is not to say that addicts should not get medical care. They should receive the best possible care available like any other person, just that at present this is not very good!
Competing interests: No competing interests
For many around the world interested in drug policy, it has been apparent for many years that global drug prohibition has been an comprehensive failure. Over the last half century, the drug market has considerably expanded with greater quantities of drugs produced and consumed, falling drug prices and increasing numbers of new and more dangerous drugs while street drugs have been and remain readily available. Even worse, deaths, disease, crime, corruption and violence have increased in leaps and bounds. Producer and transit countries are even more severely affected than rich destination countries.
The essential problems are untested drugs and an unregulated market. Redefining drug policy as a primarily health and social issue rather than a criminal justice problem is indeed the threshold decision required. We also need to move from criminal to civil sanctions. We should start regulating the drugs that can be regulated. Cannabis is the obvious place to start. But part of the market will always be beyond government control. A realistic aim is to make that part of the market as small as possible.
Edible opium was taxed and regulated in Australia until 1906 and in the USA CocaCola contained cocaine until 1903. There is no record of the sky falling in.
Drug law reform has already started in the Americas. In 2013, New Zealand regulated some 'New Psychoactive Substances' for ten months. Things are falling apart, prohibition cannot hold.
Competing interests: No competing interests
Now is the time to act before it is too late for some patients.
The current issue of "Drug and Alcohol Findings" (1) highlights the sudden reversal in 2013 of some indicators of the good progress that we have made in substance misuse treatment in recent years.
This is a quote from their conclusions which needs to be widely disseminated when considering what evidence based drugs policy should look like:
"Within the reporting year 2007/08 the BBC exposed the tiny proportion of patients who within a single year left treatment drug-free, intensifying a national policy emphasis on successful completion. Since then commissioners and services have been under reputational pressure to produce more successful completions, and in recent years, under financial pressure too. If exits are indeed being promoted to meet national or local needs and ambitions rather than those of the patient, this would make the increased successful completion rate partly a marker of a worse rather than a better treatment system."
This is a warning which we must heed now. I believe that the "recovery = abstinence" agenda that has gained traction over the last few years may be contributing to these emerging problems. The insistence on increasing the number of "successful completions", has shifted the focus from the quality of professional person centered care a person receives, to an outcome measure which either overtly or covertly pushes people to get off a substitute script and leave services - perhaps before they are ready.
Recovery is so much more than being off a script - indeed, the script itself is not the important thing for most people. They want a decent home, not to have to commit crime to feed their addiction, good family and social relationships, work and/or education, health and a hope for the future. All this is possible on a script - and takes time. There is good evidence that being on treatment is protective and helpful in several ways - we already know that - why are we going backwards?
Treatment needs to be individual and to be characterised by competent compassion. It must not be driven by external pressures on contracts and targets. Otherwise we will see more of these poor outcomes for people and increasing deaths because they cant get the treatment they need.
There is more discussion on this at www.competentcompassion.org.uk, and I have discussed the background in more detail in a previous eLetter to the BMJ (2)
Are we as professionals willing to stand up and be counted for the sake of our patients on this? That is what professionalism should be all about.
Dr Joss Bray MRCPsych FRCGP
1. http://findings.org.uk/PHP/dl.php?file=PHE_22.txt
2. BMJ 2014;349:g7493
Competing interests: I am the founder of www.competentcompassion.org.uk - which promotes a simple concept that should underpin all that we do as professionals.