HEAVY DUTY "DON'T USE DRUGS" VIDEO

TREATMENT WORKS - HUGE NEWS FROM THE U.K.

Many thanks to Darcy Ulmer of Baldy Hughes Therapeutic Community for passing on this study of SUCCESS IN TREATMENT from the U.K.

The next time some quasi-scientist wants to tell folks that treatment does not work, you might quote this study.

National Treatment Agency for Substance Misuse

“Long-term results for those who have been treated in one year found that nearly half who leave neither need further treatment nor were found to be involved in drug related off ending”

A LONG-TERM STUDY

OF THE OUTCOMES OF

DRUG USERS LEAVING

TREATMENT

SEPTEMBER 2010

EFFECTIVE TREATMENT CHANGING LIVES

www.nta.nhs.uk

NTA 2010 NTA 2010

EXECUTIVE SUMMARY

Around 200,000 people get help for drug dependency in

England every year. Most are addicted to heroin or crack

cocaine, or both. They will have been using their drug or

drugs of dependency for eight years on average before

they seek treatment.

Given their typical circumstances – heavily addicted,

in poor health and of low self-esteem, often at a peak

of criminal activity before coming into treatment - the

prospects for long-term recovery from drug addiction

can seem bleak. The medical consensus is that heroin

and crack cocaine users take several years to overcome

addiction, and spend repeated attempts in treatment

before they do.

Against this background, the annual statistical reports of

numbers in drug treatment can present a distorted picture

of a treatment system that is subject to a steady ebb and

fl ow of clients over a longer time frame. However the

National Drug Treatment Monitoring System (NDTMS)

database is now extensive enough to enable us to follow

the treatment careers of individuals over successive years.

Consequently the National Treatment Agency for

Substance Misuse (NTA) has analysed the long-term

results for those who have been treated in one year, and

found that nearly half (46%) of those who leave neither

need further treatment, nor were they found to be

involved in drug related offending.

In close co-operation with the Home Office, the NTA

matched four years’ worth of NDTMS data with Drug

Test Records (DTR) and the Drug Interventions Programme

(DIP) data to evaluate the long-term outcomes of drug

treatment for 41,475 clients who left drug treatment in

England in the financial year 2005-06. It includes both

those who left treatment in a planned way, and those

who dropped out.

This is the first time a study of this kind has been possible.

Although there is no international long-term equivalent

study based on live client data, the results compare

favourably with longitudinal studies about the prospects

of individuals’ recovery from even the most entrenched

addiction.

As a treatment programme for addiction usually takes

longer than a year to complete, these findings provide a

more meaningful assessment of treatment effectiveness

than an annual snapshot. It enhances our understanding

of what success means: for example, it was found that

many of those who ‘drop out’ do not seem to need

further treatment. Most importantly, it shows to users

and all the people and agencies who work with them to

bring about positive change that recovery from addiction

is possible.

KEY FINDINGS:

.Strong evidence that suggests sustained recovery from

addiction was found for almost half of all the clients

discharged from treatment during 2005-06. Around

46% neither came back into treatment, nor had a

drug-related contact with the criminal justice system

in the following four years. (A criminal justice contact

could be with either the Drug Interventions Programme

in the community or prison, or a positive DIP drug test

for cocaine or opiates following arrest for offences such

as burglary, robbery and theft). 

.The majority (55%) of all clients who left treatment

during 2005-06 did not return to treatment in the

subsequent four years.

. Of those who left treatment but subsequently re-

offended using drugs, 65% went back into treatment.

. As might be expected, clients who successfully

completed a course of treatment were less likely to

need treatment in later years.

. However, a high rate of those who were originally

categorized as ‘dropping out’ (43%) did not return to

either treatment or drug interventions in the criminal

justice system.

. Those treated for the most addictive substances were

the hardest to treat and more likely to relapse. Problem

drug users addicted to both heroin and crack cocaine in

combination had the poorest long term outcomes.

. Conversely, those leaving treatment for cannabis

and powder cocaine did best with 69% and 64%

respectively not returning during the follow-up period

or being identified as re-offending using drugs.

. Whether someone was discharged from treatment

free of all illegal drugs or free of dependency made

little difference to how likely they were to need further

treatment or commit drug-related crimes.

. Comparison between 2005-06 and 2006-07 treatment

exits with re-presentations measured over three years

showed significant similarity in the long term outcomes

of both cohorts.

2

NTA 2010 NTA 2010

1.1 INTRODUCTION

This paper presents the results of a study to follow up

individuals after leaving structured drug treatment services

in the financial year 2005-06 to see whether in the four

years after leaving, they re-present to drug treatment

again and/or they have a drug related contact with the

criminal justice system, after being arrested for offences

such as burglary, theft and shoplifting.

All findings are based on the analysis of collated

information from drug treatment providers through the

National Drug Treatment Monitoring System (NDTMS),

data collected from the Drug Interventions Programme

through the Drug Interventions Monitoring Information

System (DIMIS) and Drug Test Records (DTR) from

individuals who are arrested. The datasets have been

matched to create a pathway or journey map for a

cohort of individuals exiting treatment and examined to

determine whether there has been further contact with

treatment and/or drug interventions through criminal

justice agencies.

In the context of this report, contact with the Criminal

Justice Service (CJS) refers specifi cally to contacts recorded

in one of these datasets. It should be noted that while

these are the most common datasets that drug users will

appear in, some clients will have had other CJS contacts

not covered by this data: for example, arrests for a

non-drug related offence for which drug testing is not

standard practice or arrests in areas where drug testing

is not in place and where the client is not otherwise

identified as a drug user.

Individuals were excluded from the study for the following

reasons: that they were in prison at the time of leaving

treatment, that they had been recorded as dying while

in contact with treatment and if they shared attributors

(initials, date of birth and gender) with another individual.

This report cannot categorically assert that all individuals

who do not return to treatment or DIP are leading entirely

drug free lives as to do so would require each of the

40,000+ clients in the study to be personally contacted

and interviewed. Rather it uses the available datasets to

demonstrate with the best possible evidence whether an

individual’s drug use has become problematic enough

that they require treatment again or have come to the

attention of the criminal justice system and the Drug

Interventions Programme incurring the associated costs

when they do so.

Further analysis to enhance our understanding of

treatment and criminal justice journeys of drug using

offenders is currently being undertaken through the

Home Offi ce Drug Data Warehouse.

1.2 CLIENT PROFILE

A sample of 41,475 clients was identified who had left

the treatment system in 2005-06 as defined by not

being in contact at the end of the year. Two thirds of the

cohort (67%) were problem drug users (PDUs), i.e. were

recorded as presenting for treatment for opiates and/or

crack cocaine.

Over two fifths of all clients presented with ‘opiates only’

(42%) at the beginning of their latest treatment journey.

Powder cocaine presentations were fairly evenly split

between those in the 18-24 and 25-29 age bracket (28%

and 24% respectively).

Almost one-quarter of treatment exits were planned

(24%) – defi ned either as ‘treatment completed’ or

‘treatment completed – no drug use’, both denoting the

clients had completed treatment successfully, leaving free

of dependency.

The cohort was selected from the 54,000 adults

discharged from structured drug treatment in 2005-06.

Individuals were excluded from the study if they were

in prison at the time of leaving as they will have been

incarcerated for part or all of the study and also as many

will have continued receiving treatment during and

directly after custody. In addition, as individuals were

identifi ed by only attributors (initials, date of birth and

gender) rather than names and addresses, any duplicate

attributors were excluded.

Once the cohort of treatment leavers in 2005-06 was

selected, it was then necessary to be able to determine

if they had subsequently either returned to treatment or

had shown up in any of these criminal justice datasets.

This was ascertained by bringing together data from

the NDTMS and DIP including that collected through

mandatory drug testing of arrestees covering the period

2006-07 to 2009-10. Once this dataset was assembled it

was then possible to see if any of the 41,475 clients had

turned up again in the following four years.

3

NTA 2010 NTA 2010

TREATMENT

LEAVERS

2005-06

2006-2010

NDTMS

DIR

PRISON & COMMUNITY

DRUG TEST

2006-2010

2006-2010

The datasets that have been used here are the most

common that people that are using drugs problematically

will turn up in. Therefore an individual not subsequently

appearing in any of them after leaving drug treatment

would indicate a likelihood of sustained recovery from

dependency. However, as noted previously, they may

have presented to other criminal justice agencies having

committed offences triggered by their drug use and they

will not be identified within this piece of work.

There will sadly be a small number of clients who died

after they left treatment during the four year follow up

period and due to the methodology used it has not been

possible to exclude them from the study. It is recognised

that their inclusion will marginally over estimate the

numbers who are in ongoing recovery. Clients recorded as

having died in treatment were, however, excluded from

analysis at the outset.

Conversely, because the attributors and not the full

names of clients have been used in the analysis, there is a

chance that when an individual is later found in a dataset

it is not in fact the same person as in the original sample,

but instead someone sharing their initials, date of birth

and gender. Although steps have been taken to limit

false-matching it has not been possible to entirely avoid

this, nor the effect that this will have in over estimating by

a small amount the numbers who re-present.

A detailed explanation of the methodology used can be

found in appendix A.

4

NTA 2010 NTA 2010

2 THE RESULTS OF THE STUDY

The analysis of matched data revealed that 46% of clients

in the study did not return either to drug treatment or

to drug interventions within the criminal justice system

(CJS) within four years. The 22,428 re-presentations to

drug treatment or to the criminal justice system mostly

comprised of individuals who returned directly back to

structured treatment; however, a sizable proportion had

their first subsequent contact at the custody suite and in

prison following their initial discharge in 2005/06. The

diagram below demonstrates the fi rst subsequent event

of the 41,475 clients in the four years following their

discharge from drug treatment.

TREATMENT EXIT 2005-06

(N=41,475)

NO SUBSEQUENT EVENT OF TREATMENT OR

DRUG-RELATED CRIMINAL JUSTICE CONTACT

N=19,047 (46%)

SUBSEQUENT EVENT

N= 22,428 (54%)

TOTAL THAT RETURN TO

TREATMENT

N= 18,666 (45%)

n=11,641 (52%)

n=3,417 (15%)

RE-PRESENT TO DTR

n=5,571 (25%)

RE-PRESENT TO PRISON

n=1,799 (8%)

RE-PRESENT TO

COMMUNITY DIP

TOTAL THAT HAVE INITIAL SUBSEQUENT DRUG-RELATED

EVENT IN CJS N=10,787

n=7,025 (65%)

5

NTA 2010 NTA 2010

Just under half of the clients discharged returned to

treatment 18,666 (45%), with 11,641 re-presenting

straight to treatment and a further 7,025 having a drug-

related criminal justice contact fi rst and then receiving

structured drug treatment afterwards. The remaining

3,762 clients had a subsequent drug-related contact with

the CJS but then didn’t have a further drug treatment

contact.

As would be expected, clients who left treatment

successfully were less likely to need further treatment

than those who dropped out, with 57% of clients having

a planned discharge either not returning to treatment or

to drug interventions within the CJS. As can be seen from

the table below, there was little discernible difference

in outcomes between the two recorded categories of

successful discharge: either ‘treatment completed’ or

‘treatment completed – no drug use’, both of which

denote the client has left free of dependency.

Perhaps more surprising was the re-presentation rates

of those who dropped out of treatment: more than two

fifths of those clients with an unplanned exit (43%) did

not re-present at any time in the subsequent four years,

suggesting that many had already received what they

needed to overcome their dependency before choosing

to leave. This corroborates what some practitioners

have argued: that although drop-out is usually signalled

by relapse, a proportion of those in treatment simply

walk away once it has met their clinical needs without

engaging with the formal administrative discharge

process required by NDTMS.

Analysis of the time elapsed between initial discharge

and re-engagement with services indicated no discernible

difference between planned and unplanned exits.

The proportion of clients readmitted to treatment or drug

interventions in the criminal justice system within the

four-year window varied greatly between drug groups,

with 64% of clients using either crack cocaine, opiates

or both returning, compared with only 33% of clients

using other drugs. Those who presented originally with

combined opiate and crack cocaine use were more likely

to reappear than those with sole use of either drug (63%

opiate only, 51% crack only and 72% opiate and crack

in combination). This is consistent with previous studies,

which have identifi ed worse outcomes associated with

poly drug users.

The probability of not returning to treatment or drug

interventions in the CJS was notably higher for cannabis

and powder cocaine users, with 69% and 64% not representing

to either.

Reason for leavingtreatmentNumber ofindividuals leavingtreatment 2005/06Number notreturning totreatment / CJSPercentage notreturning

Completed -

no drug use

3353 1886 56

Completed 6417 3650 57

Unplanned 31705 13511 43

6

NTA 2010 NTA 2010

Differing rates of re-presentation were observed between

the age groups, with those aged 40+ being least likely to

return (43%), followed by 18-24 year olds (54%). Those

aged 25-29 were the most likely to reappear, with 60%

having done so.

RATES OF RE-PRESENTATION TO

TREATMENT/CJS BY SUBSTANCE

OPIATES ONLY

CRACK COCAINE ONLY

OPIATES AND CRACK COCAINE

COCAINE POWDER

CANNABIS

OTHER

0% 20% 40% 60% 80%

RATES OF RE-PRESENTATION TO

TREATMENT/CJS BY AGE GROUP

40+

0% 20% 40% 60% 80%

7

NTA 2010 NTA 2010

However, the relationship between age group and

readmission rates was not uniform across presenting

substances. The lower incidence of readmission in the top

age band was clearly visible among opiate only users, but

there was no discernible relationship between age and

readmission rates for crack cocaine only users.

PROPORTION OF READMISSIONS FOR ALL 2005-06

EXITS (N=41,475)

18-24 25-29 30-34 35-39 40+

0%

10%

20%

30%

40%

50%

60%

70%

ALL

OPIATES ONLY

CRACK COCAINE ONLY

CANNABIS

TIME TO RE-PRESENT (N=22,428)

AGE GROUP

LESS THAN A YEAR

1 TO 2 YEARS

Fifty-seven percent of individuals who returned did so in

the first year and the number of re-presentations roughly

halved between each year after that. Many of those

whose fi rst subsequent contact was with the CJS were

later re-engaged in treatment. At 12 months following

discharge, 30% of those appearing first in CJS data

had also re-started treatment; after four years, 65% of

everyone with a subsequent CJS contact also had further

treatment.

2 TO 3 YEARS

3 TO 4 YEARS

The analysis also demonstrated that those who had an

unplanned exit (categorised as ‘dropped out’) and a

subsequent event, came back quicker than those who

had a planned exit, with 59% of subsequent contacts

occurring within a year compared with 47%.

Further analysis has been carried out to compare the representation

rates of clients leaving structured treatment

services in 2006-07 with those found in 2005-06, to see

if similar rates and profi les of those not returning were

found. In most cases they were and the results of this

work can be found in appendix B.

8

18-24 25-29 30-34

AGE GROUP

35-39 40+

0%

10%

20%

30%

40%

50%

60%

70%

80%

NTA 2010 NTA 2010

3 CONCLUSION

The NTA has completed an evaluation of the outcomes

of people leaving drug treatment using an initial cohort

of 41,475 clients leaving structured treatment during

2005-06 and seeing if they subsequently came back

to treatment or turned up in drug interventions in the

criminal justice system (CJS).

Examination of all clients exiting in 2005-06 revealed

that 46% didn’t return to drug treatment nor had a drug

related contact with the CJS in the following four years.

This would suggest the majority of these individuals

are managing to sustain their recovery from addiction

though it is not possible to confirm this from the analysis

presented in this report.

There were significant variations in the rates of representations

depending on the substances that the

clients had presented with, demonstrating the difficulty

of achieving long term recovery when using both opiates

and crack cocaine.

Successfully completing a treatment episode was the

best predictor of long term outcomes, but there were

also a significant proportion of those clients who were

not recorded as completing their course of treatment,

who appeared to have taken the benefits from the

interventions they received and overcome dependency in

the four years of this study.