ADDICTION T DAY
RESEARCH
REHABILITATION WORKS: THE EVIDENCE
A myth is doing the rounds that there is no evidence that rehabs work –
much like scientists could not prove until four years ago that bees could fly.
Deirdre Boyd gathers some of the evidence, and outlines the necessity
to read the true figures behind detractors’ remarks
“There is a lack of evidence that rehab works” is
a myth which the National Treatment Agency for
Substance Misuse has been spreading for some
years. Sadly, we have heard it even from Cabinet
and other members of government who know
people in recovery, know how they quit their
addiction – but feel they cannot support successful
methods until they are publicly proven.
Well, the research is out there, and has been
for quite some years. What is more, the evidence
base for rehabs and 12-step linked treatment is
stronger than other forms on which money has
been splurged these past nine years.
Of course there is a role for harm reduction,
particularly as engagement into treatment/
recovery. But UK practice became harm
maintenance when it instead replaced treatment
and stalled patients from progress.
WHO PAYS FOR THE RESEARCH?
Recruiting independent researchers to find
clients and ex-clients, follow them for years
with questionnaires and interviews, collate the
information and verify it, then interpret the
results is a long and costly task – it is costly even
when inhouse staff undertake some of the work.
When Broadreach commissioned what was
the largest survey into outcome predictors in
1994, it cost over £100,000. Despite the
importance of this work, and despite how
financially punitive it is for rehabs, there has
been little or no government support to gather
this evidence. And the NTA’s Top measurement
tool is not suitable for rehabs – see below.
VERBAL VS EMPIRICAL EVIDENCE.
The NTA Top measurement tool is self-report
only. The outcomes are not independently
verified, and research by Dr David Best and Dr
Jason Lutty describe how they are not accurately
filled in. Even if they were, Top does not measure
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methadone use or other addictive drugs such as
ecstasy or benzodiazepines, so cross-addiction is
invisible. In other words, reductions in specific
drugs rather than the benefits which derive
from full recovery – which rehabs specialise in
delivering – are noted. Despite these limitations,
the NTA quotes Top/NDTMS self-report figures
instead of worldclass rigorous empirical research.
WHAT DO WE MEAN BY ABSTINENCE?
When we read about “abstinence” outcomes in
rehabs, it means abstinent from all mood-altering
substances including alcohol. For patients to stay
off all drugs, they must be working a psychosocial
relapse-prevention programme which addresses
causes and redresses behaviours. But in harmreduction/methadone-maintenance services, it can
be defined as abstinence from only one drug;
old behaviours usually continue, as does relapse
onto other drugs. For example, in NTORS about
40% of methadone maintenance patients became
dependent on alcohol, and references elsewhere
to “ex-heroin users” can mean they are still using
other drugs. It is vital to ask what “abstinence”
means when you read any report.
It is also not understood that rehab staff
and people in true recovery use shorthand when
they talk about “abstinence”. They do not mean
merely desisting from substances, but tacitly
know that abstinence is sustainable only when
behaviours and relationships are healthy (eg,
with family), when relapse triggers are addressed,
when childhood traumas are faced and no longer
influence actions, when life is lived with honesty
to self and others (no crime), when amends are
made for past actions and a determination made
not to create future problems, and a promise is
made to help others suffering from addiction.
Many clients train for a career, and honest living.
What research paper mentions all these
outcomes in one word?
www.addictiontoday.org
WHAT DO WE MEAN BY REHAB?
Usually, we mean treatment programmes of four
weeks or more in a residential setting, where the
therapeutic process of change is linked to steps
in Alcoholics Anonymous, Narcotics Anonymous
or other 12-step fellowships. This means that
patients can join these free support networks for
as long as they need, after they leave treatment.
However, there are some excellent daycare
and ‘quasiresidential’ programmes using the same
principles, the only difference being that the
treatment provider does not offer accommodation.
There are also sessional/private therapists who
treat clients with these same principles.
Until we universally agree a better term, the
word “rehabilitation” covers all these settings.
What they have in common is that they help
people give up their drugs of harm and better
their lives, and sustain those benefits long term.
RESIDENTIAL REHABILITATION:
GOVERNMENT REVIEW 2009.
The government’s Commission for Social Care
Inspection and the NTA jointly carried out a
review of treatment services in 2008. “Residential
rehabs outstrip other sectors in every outcome
group we measure,” announced CSCI inspector
David Finney.
www.addictiontoday.org/addictiontoday/2009/03/
tier-4-review-rehabs-jan-2009.html
CLOUDS INDEPENDENT RESEARCH.
As long ago as 1995, an independent research
psychologist was commissioned and allowed to
select from any block of admissions into Clouds
House rehab. Of 166 randomly chosen ex-clients,
61% were abstinent from all mood-altering
substances 30 months after treatment.
Of the predictors of successful outcomes, two
were important. First was discharge status: 82% of
people completing the programme satisfactorily
ADDICTION REC VERY FOUNDATION
November | December 2010
showed good outcomes at follow-up. Second,
89% of ex-patients attending 12-step meetings
were abstinent at follow-up.
DORIS: DRUG OUTCOME RESEARCH IN
SCOTLAND.
December 2006 saw the publication of Abstinence
and drug-abuse treatments: Results from the Drug
Outcome Research in Scotland study. It followed
1,033 drug users contacting treatment services
who were able to become and stay abstinent 33
months after starting treatment – and identified
which services were most closely linked with such
drug-free results.
The Doris researchers defined abstinence in
terms of people being totally drug free (other
than alcohol or tobacco use) for at least 90 days
before their research interview. 29.4% of those in
contact with residential rehabilitation services but
only 3.4% of those in contact with methadone
maintenance services had a 90-day drug-free
period nearly three years after having initiated a
new episode of treatment, the report stated.
www.addictiontoday.org/addictiontoday/files/
DORIS-Abstinence-Final.pdf
NTORS: NATIONAL TREATMENT
OUTCOMES RESEARCH STUDY.
The largest UK research into outcomes of drug
treatment came from the National Treatment
Outcome Research Study, which published
changes in substance use, health and criminal
behaviour during the five years after intake.
The NTORS authors note that “Clients in the
rehabilitation units included the more chronic,
long-term users with the most severe problems.
Rehabilitation clients presented with the longest
heroin careers, they were more likely to be regular
users of stimulants (especially cocaine), and were
more likely to have shared injecting equipment.
There were also more heavy drinkers among the
clients entering the rehabilitation programmes.
Rehabilitation clients were more likely to have
been actively involved in crime and they had been
arrested more often than the other clients.”
Despite this, over 38% of the “residential
clients” were abstinent from six illicit target drugs
4–5 years after treatment compared to 35% of
methadone clients. The gap is greater than it at
first appears.
Methadone users were described as abstinent
when using not only that drug but also if using
psychoactive drugs other than “illicit heroin,
nonprescribed methadone, crack or powder
cocaine, non-prescribed benzodiazepines and
amphetamines”. So they could still be using
prescribed heroin, cannabis, ecstasy...
Second, the NTORS researchers bafflingly
mixed up NHS inpatient/detox outcomes with
residential rehab instead of separating them out,
even though anecdotal evidence is that the former
have little success (so bad in one notable case that
it led to a call for retoxing clients before releasing
them) and the latter far greater success rates.
Thus we can conclude that the successful
outcomes for residential rehab are higher than
the 38% quoted in NTORS.
www.addictiontoday.org/addictiontoday/files/
ntors_5.pdf
DOES TREATING PEOPLE INCREASE
THEIR CHANCE FOR ABSTINENCE?
Followed 269 people in full (abstinent) recovery.
“The only type of formal treatment service which
was a key factor in helping drug users to stay
abstinent was residential rehab”, found researchers
Dr David Best, Jessica Loaring and Safeena
Ghufran. “Formal long-term structured (not
rehab/TSF) treatments played only a peripheral
role in the recovery journeys.”
www.addictiontoday.org/addictiontoday/files/
AT113Best-LifeCourse.pdf
www.addictiontoday.org
PREDICTORS OF 4YEAR OUTCOME
OF COMMUNITY RESIDENTIAL
TREATMENT.
Predictors of 4-year outcome of community residential
treatment for patients with substance use disorders,
published in 2008, examined systematically how
predictors of substance use treatment outcomes
worked in over 2,000 male patients. “Greater
substance use severity, more psychiatric symptoms,
more prior arrests and stronger belief in AArelated philosophy at treatment entry predicted
improvement significantly in substance-related
problems four years later.
“At the one-year follow-up, being employed
and greater use of AA-related coping predicted
outcome significantly,” the research confirmed.
THE GUIDE TO REHAB - WHAT REALLY
WORKS.
20 research facts everyone should know about
rehab treatment for alcohol and drugs dependency.
In 1999, Dr David Best, myself and an ex-CEO
of EATA met to initiate an easy-to-use reference
document about addiction treatment, covering
key issues and based on incontrovertible research.
www.addictiontoday.org/addictiontoday/2008/01/
the-guide-to-re.html
GET FIGURES FROM PROBATION.
Providence Projects claims that DTTO figures
for the three years that it held the contract for
Dorset (before the NTA stepped in) “clearly
showed that our outcomes of success were over
60% – these were figures probation put together”.
This article and links to the research papers are at:
www.addictiontoday.org/
addictiontoday/2010/10/
rehabs-work-researchon-success.html
Image: LiveStock
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