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.
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