The BBC has today questioned the National Treatment Agency (NTA) over certain prescribing practices in drug treatment described in an NTA-commissioned report into contingency management in the UK.
The NTA-commissioned report, Are contingency management principles being implemented in drug treatment in England? was published in April this year. Contingency management is a system to provide disincentives to continue drug misuse and incentives to continue in treatment.
Evidence from the US suggests that contingency management involving positive reinforcement for clients in drug treatment has worked in reducing drug use and in ensuring clients are retained in treatment. ‘Positive reinforcement’ may take the form of low-value monetary vouchers to enable clients to buy food or clothing.
The National Institute for Clinical Excellence (NICE) made recommendations earlier this year that contingency management systems should be implemented in drug treatment services in England “as part of the phased implementation programme led by the NTA, to reduce illicit drug use, encourage harm reduction and/or promote engagement with services for people receiving methadone maintenance treatment.”
The NTA-commissioned report into contingency management focussed on the management of clients who are misusing both heroin and crack cocaine. The authors carried out a survey assess to what extent contingency management principles were already being implemented in drug treatment in England, and to assess clinicians’ attitude to their use. The survey revealed that “a range of positive reinforcement methods are used routinely by services.”
The report went on to state:
“Just under a third of clinics told us that clients might be made eligible for consideration for increased doses of opiate substitute, while over a quarter said that providing urine samples negative for cocaine would possibly make clients eligible to choose the type of opiate substitute prescribed.
“Less commonly reported forms of positive reinforcement contingent on clean urine samples included progress from supervised consumption to take-home privileges, fortnightly clinic attendance instead of the standard weekly, prescribing antidepressants and eligibility for a detoxification programme. Overall, eight out of ten services reported using at least two of the positive reinforcement methods described above.”
In an interview broadcast on BBC Radio 4’s Today programme Paul Hayes the chief executive of the NTA, was questioned as to whether drug users who provide a positive urine sample should be given extra drugs as a “reward” for “good behaviour”. Mr Hayes responded by expressing concern over the ethical basis of this approach and distanced it from the practices of contingency management techniques outlined in the NICE guidance.
Commenting on the report Martin Barnes, chief executive of DrugScope, said:
"My initial reaction on hearing comments made by the NTA this morning was to share their concern about the practices described by the BBC.
“However, it would appear that the original BBC story, based on the NTA study, may have been misleading. The study does not conclude that people in drug treatment are routinely being offered extra drugs as a reward for 'good behaviour'.
“The report referred to was a study published in April this year which looked specifically at contingency management options for those with crack/cocaine problems. An NTA report on drug treatment services for crack cocaine users, also published in April, confirmed previous studies that retaining crack users in treatment is much more difficult because there is no drug substitute for crack cocaine as there is for heroin (e.g. methadone). However, many crack users also have a problem with heroin and if you can stabilise a crack/heroin user in treatment with methadone then other aspects of their chaotic lifestyle including crack use can also be contained or reduced.
“As the report pointed out, many clinicians have concerns about the ethics of 'rewarding' users whatever the incentives might be. But there is a particular problem with crack cocaine - and in the future we may be looking at more people coming forward for treatment for powder cocaine problems and maybe even methamphetamine. They are all stimulant drugs and the same issues will arise. So clearly more research is needed about the most effective way of retaining stimulant users in treatment.”
For more information please contact Ruth Goldsmith in the DrugScope Press Office on 020 7940 7517 (07736 895563 out of hours) or at press@drugscope.org.uk
