healthmedicinet

Recently I found a paper I wanted to read about the policy shift from harm reduction to recovery in the UK and the impact on attitudes to methadone. It’s a fascinating subject. As I say, I really wanted to read it, but I kept getting distracted by a persistent question: what’s the difference between recovery and “recovery”? My question was that simple.

You see, every time recovery is mentioned in the paper they call it “recovery”. I kept on asking myself – why did they put recovery in inverted commas? It ends up with the reader forming an opinion on what the authors think about recovery, like it is an odd or distasteful word that has to be held at arms length. A word perhaps that other people use – one that couldn’t really be trusted to stand on its own. They do this all the way through the paper and frankly I found it very strange.

Despite the distraction, I tried to come at the paper even-handedly. The paper in question is called Substitution Treatment in the Era of “Recovery”: An Analysis of Stakeholder Roles and Policy Windows in Britain and comes out of the Drug Alcohol Research Centre at Middlesex University.

The paper starts by laying out the historical context to the shift in policy stemming in some way from the polarised debate about maintenance vs. abstinence, concerns raised about people getting ‘stuck’ in treatment and the publication of the UK Government Strategy in 2010 with the focus on wellbeing, citizenship and freedom from dependence. Of course the Scottish Government were ahead of the game on this with their strategy, The Road to Recovery, (no inverted commas there) published two years earlier.

The researchers identified 20 folk who were stakeholders with regard to ORT (Opioid Replacement Therapy). The initial members of the group of 20 were identified from key documents published over ten years or so and the rest by snowballing. The stakeholders included policy makers, advocacy organisations, professional associations, researchers, those from the treatment sector and those with an economic stake or interest. The authors lay out an argument that two groups of stakeholders were influential in terms of national policy development: those calling the previous system of maintenance ‘problematic’ and setting the agenda and those who have ‘been powerful in designing and crafting the drug policy itself.’

According to the paper, the first group took advantage of “a rare window of opportunity” to heavily influence policy towards recovery from the pre-existing harm reduction focus. The Centre for Social Justice, along with researchers, residential treatment providers and the media, are implicated in agitating for change. Individuals are also named. The DORIS study from Scotland, which suggested people wanted to achieve a drug-free status, catalysed change while other influential research suggested treatment was process-focussed with little therapy on offer.

The paper suggests that a second group of hidden participants moderated and shaped policy direction to prevent extreme positions such as time-limited methadone prescribing or a wholly abstinence-focussed strategy. An expert group chaired by John Strang included stakeholders with a wide range of views to try to achieve consensus. This group, like the Expert Review group in Scotland, found that Opioid Replacement Therapy should continue to have “an important and legitimate place within recovery-orientated systems of care.”

The conclusion leaves us hanging. What do the authors actually think? It’s implied rather than stated. The tone of the paper tells us more than the words. How I wish they’d been more frugal with their inverted commas, but, of course, there is intent there.

I’m interested to compare what’s happened in Scotland with the developments in England and Wales. While they touch briefly (a paragraph) on differences in the evolution of the Scottish drugs policy, they seem to neglect the huge overlap with the UK policy and the fact that the Scottish policy has cross-party support. So essentially Scotland ended up in a similar place with a similar view and a similar policy without the influence of the key stakeholders implicated here in the UK policy shift. The Scottish National Party is far removed from Conservative polices and pressures, yet the two have ended up as policy bedfellows.

With Scotland and England ending up in much the same place could it be that an inclusive recovery-oriented policy is actually a good thing per se, something desired by patients and providers alike and something that was going to happen one way or another anyway, rather than a Machiavellian fait accompli by right-wing lobbyists?

The views and activity of patients/clients and what they wanted from treatment are scantily considered here, yet service users and those in recovery have had a voice. The fact that we have a recovery movement at all, a type of civil rights movement, should tell us that some clients were not getting what they wanted from the services we were providing. Those voices were not impotent in helping to change policy; very much the opposite. It’s worth noting that the authors put the recovery movement in quotes too (it’s a “recovery movement”) as if, once more, they seek to diminish legitimacy and keep us in our place.

I found this paper to be an impressively referenced opinion piece, ironically without explicitly stating an opinion or making recommendations. It’s an unusual bit of “research” and while it may add to debate, I’m not sure it ultimately leaves us any better off.

Duke, K., Herring, R., Thickett, A., Thom, B. (2013). Substitution Treatment in the Era of “Recovery”: An Analysis of Stakeholder Roles and Policy Windows in Britain Substance Use Misuse, 48 (11), 966-976 DOI: 10.3109/10826084.2013.797727

A version of this article was originally published in recovery.postach.io.