Opioid Substitution Treatment: UK vs France

By Shane Levene 09/25/16

You can't prescribe medication and then when it does not work blame the patients! To change that, the expectations and hopes for what OST can achieve need to be redefined.

A poster in England with a picture of syringes and the text "Begging: Watch your money get wasted"
A controversial campaign in Nottingham by the city council and police. via Jason Batterham / Shutterstock.com

In the last 15 years, Opioid Substitution Treatment (OST) in the UK has not only failed the people it was designed to help but the wider community at large. The policy behind OST has become increasingly punitive in nature and, since 2010, the government's move towards "recovery" based treatment has been the vehicle on which a creeping culture of austerity has wormed its way in. For the slightest misdemeanors, service-users face sanctions, all geared towards the economizing of medication and resources—often relieving users of their scripts altogether. On such a wind, the vile stench of populist politics wafts rotten throughout the nation. And with further cuts to health and care services on the horizon, things are only set to get worse. All this is a far cry from what is happening across the English Channel in France, where a philosophy of harm reduction and social reintegration pervades, and where, as a consequence, OST thrives and is a positively healthy experience for service-users. And yet, both countries have the exact same forms of treatment at their disposal. It all goes to show how with a different philosophy, and a different criteria for success, methadone and buprenorphine (brand names: Suboxone, Zubsolv, Subutex) can be quite effective in the fight against heroin addiction. 

Since I first entered OST in the UK, many things have changed. In some small pockets of the country there has undoubtedly been some improvement, while in the main, things have gotten far worse. What hasn't changed is the post-code lottery which persists, whereby addicts remain at the whim of local authorities and whatever recovery politics they espouse. But everywhere, in greater or lesser degrees, the philosophy of punishment is rife. Drug addicts are held hostage for their treatment, strong-armed to produce clean urine samples and coerced to reduce treatment. It remains today, in 2016 in the UK, in the context of a 32% rise in heroin and morphine related deaths, that users are punished for telling the truth. 

In a report last year, UK drug charity Release remarked the same. They qualified their criticism with a short list of punitive measures employed by OST centres:

• "Therapeutic discharge" (clients suspended from a service for behavioral issues, often very minor) 

• Coerced reduction of prescribed medication

• Methadone prescription being made conditional on engagement with other interventions

• People moved to daily supervised consumption, regardless of circumstance

It is a system hard-wired for failure.

Walking into an OST centre in France for the first time can come as a bit of a culture shock. The staff are happy and welcoming, and neither methadone nor Subutex is locked away in safes nor distributed from behind lock-down security shutters. Medication is kept in an unlocked cupboard and is distributed quite freely to clients. Service-users do not conspire to steal the medication nor ride in with shotguns to hold the place up. There is an honesty and a respect which exists between staff and clientele. It allows for a much better treatment environment and also frees up the health worker to do what they are trained to do: help people (not police urine tests and dole out punishments). The criteria for success is wholly different to that in Britain. In the French system punishment and retribution have no place at all. 

In 2013, the French government went forward with proposals for drug centers and substitution clinics to concentrate their efforts on addictive behavior and the social and cultural reasons behind it. They seem to have accepted the fact that addiction is here and is all but impossible to rake out using the current methods at their disposal. In light of that, they have opted for a focus on prevention, harm reduction and the stability and general health of addicts. Results of urine tests and questionnaires are not used to punish the service-user, but used purely for statistical purposes. OST is not offered with the unrealistic expectation of having people totally quit heroin. It is given in the hope of stabilizing addicts, of removing the desperation that often accompanies addiction in absence of a substitute backup. And there is a real noticeable effect of such a policy: drug-related crime is way down compared to UK levels, so too are social problems of housing and unemployment that are often a result of reliance upon illicit drugs. Without the pressure of total abstinence being forced upon them, with realistic goals of what OST can achieve, French treatment users can be successful without being totally drug-free. And that brings about the most surprising consequence of all: left to their own devices, without constant pressure bearing down upon them, French addicts in treatment achieve far higher rates of total abstinence than their British counterparts. 

The main problems facing OST in the UK are conflicts over cost, ideology, and the reality of what OST offers and how it should best be prescribed. Aware that the results of studies did not fit with their desired policies, the latest Conservative government has purposely worked in opposition to evidence-backed treatment. Claiming that the system had become "defeatist" with patients "parked on methadone," they pressed ahead with a policy of "recovery"—roughly translated as people being thrown off their scripts if they didn't get off them themselves. 

If the UK is going to have a similar success with OST as we see in France, it will need to radically rethink the philosophy that underpins treatment and prescribing practices. We know that OST does not work as was once hoped. Neither methadone nor buprenorphine is a cure to heroin addiction. Even in combination with counseling and mental health support, the statistics are appalling. But they are only appalling in light of the unrealistic end goal that governments are seeking. For the vast majority of addicts entering OST, the present marker for success—long-term abstinence—will fail them. Of course, the government will not admit that. They remain adamant that the system works if the addict wants it to. But the point of health care is that it should work regardless. You can't prescribe medication and then when it does not work blame the patients! To change that, the goalposts for success need to be moved; the expectations and hopes for what OST can achieve need to be redefined. Until such a time, success is just not possible. 

UK drug treatment policy has created a generation of failures. The addict who "screws up" ends up apologizing to the world. He's like an admonished dog. Key-workers are very quick to remind you that they cannot form personal bonds, but when you give a dirty urine it suddenly becomes very personal. The only place those in treatment can find solace is amongst other users. The system is indirectly pushing users right back into the midst of the problem. It seems ridiculous that being kicked off from one's script could come as a relief, yet many people who have passed through OST will sympathize with such sentiments. That, right there, is the people being let down. And not just the service-users but the whole of society, where such letdowns may have far wider repercussions. 

As Britain continues its sexual tango with Europe, flirting around the dotted line of legally signing out, it would do well to observe some of the successful policies and advancements that many European countries have implemented. But there the real problem rears its head again. This is not about Britain getting it wrong; it is not even really about policy, nor harm reduction and stabilization as against a false idea of total recovery. It all comes down to dirty politics: finance and budgets and policies specifically designed to woo voters. And though the government goes on record criticizing the charities and enterprises who have bought their drug and alcohol care packages, in fact, the two work hand-in-glove and are making secretive exchanges down back alleys all of their own. There exists a toxicity of policy, a bad batch going around. Only for those entering treatment, caught up in this political circus, there is no escape, nor any viable alternative.

If Britain is to make any headway into the drug epidemic that has swept over its shores, it will need to stop taking cheap shots at health care budgets and come up with a cross-party consensus on a long-term policy plan that cannot be meddled with each time a new fart blows into the halls of 10 Downing Street. It could borrow greatly from its Gaelic sister, could even—just to remain historically consistent—plunder her policies. Whatever way it chooses, Britain needs to redefine what success for OST can be, must admit that neither methadone nor buprenorphine is any real cure to addiction. Until it does, the future for a new generation of users looks as pessimistic as that of the last, falling in and out of treatment until the body gives up on itself entirely. 

Shane Levene is a British writer and poetaster. He first found critical acclaim through a cult following that built up around his online writing on Memoires of a Heroinhead. He is the hand behind The Dirty Works of Shane Levene and the author of The Void Ratio. He lived in France for 12 years and has vowed to never return again.

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Shane Levene is a British writer and poetaster. He first found critical acclaim through a cult following that built up around his online writing on Memoires of a Heroinhead. He is the hand behind The Dirty Works of Shane Levene and the author of The Void Ratio. He lived in France for 12 years and has vowed to never return again. You can follow Shane on Twitter.