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May 27, 2022

How does rehab work in the UK?

| 17 minute read

Date: 27-05-2022

Written by: Dominic Denison-Pender, Business Development Director at The New Life Centre.

Medically Reviews by: Dr Amal Beaini MBChB FRCPsych (Medical Director and Consultant Psychiatrist at The New Life Centre)

Introduction

What follows is intended to give an idea of how addiction rehab currently works in the UK and contrasts this with the often dramatic advantages offered by The New Life Centre (NLC) in terms both of patient experience and of outcomes.  

The launch of The New Life Centre addiction treatments in 2022 reintroduces the proven approach of The BONDS Protocol to address the shortcomings of a UK addiction rehab and treatment scene that is frankly failing to provide either the success rates that patients should be entitled to expect or the conditions under which most addiction sufferers would, if offered a choice, like to be treated. 

While The BONDS Protocol as administered at NLC works best for all types of substance addictions, the specifics vary between the substances for which treatment is being provided (e.g. between alcohol and drugs, and between different types of drugs).  To start with alcohol is legal while the drugs we are talking about here are not (except under limitedclinical use by a presciber).  Secondly, drug addiction treatment (and especially opioid addiction) is far more difficult than alcohol treatment from a technical point of view.  Much of the prevalent drug addiction treatment is based on an approach originally developed for alcoholism (e.g. The Minnesota 12-Step programme) and has poor outcomes for opioids.  The NLC starts from the success of The BONDS Protocol with opioids, which soon developed well established treatment protocols for alcohol, cocaine and most illicit drugs.  

What does rehab mean in the UK?

In the UK there are fundamental distinctions to be made between:

  • Publicly funded rehab (NHS via local authorities)
  • Privately funded rehab, with a further distinction to be made between:
    • Facilities run as charities
    • Facilities run as businesses.

and:

  • Residential/inpatient treatment
  • Outpatient treatment, sometimes referred to as “treatment within the community”.

In the UK there are some 1,700 drug treatment centres of which 137 offer inpatient services and 68 offer detox.  Most of these are small.

The vast majority of NHS addiction treatment is outpatient.  A continuing erosion of funding has left the NHS with only 5 of its own inpatient addiction treatment units.  In general these serve only their local areas leaving most of England and all of Scotland, Wales and Northern Ireland out of reach of such NHS facilities.

Thus residential addiction rehab is almost all privately run, whether on a business or charitable base.  NCL is a private clinic run as a business to independently grow in its  future expansion to later include the public sector.

According to Public Health England, there were 275,896 people in England in contact with drug and alcohol services between 1 April 2020 and 31 March 2021. Over half (51%) received treatment for problems with opioidss. A further 21% had problems with other drugs and over a quarter (28%) had problems with alcohol.  In Scotland it is estimated that over 30,000 people receive drug addiction treatment in a year.

According to NTDMS, in 2020/21 only 4.3% of those in addiction rehab were in some form of inpatient setting (3.9% for opioids, 13.0% for non opioid drugs and 5.3% for alcohol).

What is the process of rehab in the UK?

The public funding of addiction rehab is in the hands of the local authorities. The squeeze on local authority finances that has intensified since the financial crisis of 2008 has placed severe restrictions on the funding of addiction treatment, and in particular on local authorities’ willingness to fund residential rehab.

In general the addiction sufferer’s GP becomes involved in the referral process at some stage, but psychotherapists, consultants and, where prescription opioids (painkillers) are involved, pain specialists might recommend treatment.  However, the initiative comes from the individual addiction sufferers and their family and friends.  According to NTDMS, in 2020/21 of all new referrals into addiction treatment, 63.5% came from “self, family and friends”, 20.7% from health services and social care (including 8.3% from GPs), 5,8% from criminal services and 10% from other or unknown sources. The message here is if you or a family member needs rehab, contact The New Life Center directly.  They are the best placed to advise on the way forward.

What are the 5 stages of rehab?

The BONDS Protocol as practised at NCL has its own specific 5 stage rehab programme comprising:

  • Pre admission assessment: to ensure that the BONDS protocol is right for the patient
  • Day 1 Admission Assessment and Dual Diagnosis: a psychiatric assessment to establish both the specifics of the addiction or addictions as well as any mental or physical health conditions that underly the addiction.  This process, carried out by a highly specialised and experience addiction psychiatrist, also determines the precise requirement of the treatment
  • 7-day Detoxification and Recovery: starting on Day 1 and carried out under mild sedation (but never under anaesthesia) to help the patient achieve abstinence without experiencing the very unpleasant and dreaded withdrawal symptoms
  • Relapse prevention: administration of the inhibitor Naltrexone which blocks the effects of the substance if relapse is attempted and dramatically reduces cravings in the first place
  • Followup aftercare and therapy, is normally administered on an outpatient basis by the NLC’s Multi-discipline team  (MDT) supported by  psychotherapists based near the patient’s home.

The BONDS Protocol differs fundamentally from other addiction treatment programmes currently administered in the UK.  There are many variants, but the typical patterns (for opioids) in the UK other than NLC are:

  • for outpatients, opioid substitute treatment (OST), replacing illegal substances (e.g. heroin, fentanyl) or prescription opioids (e.g. Oxycontin, Tramadol) with legal opioid substitutes (e.g. Methadone, Buprenorphine) and attempting gradually to wean the patient off the substitutes
  • for patients in residential treatment, detoxing patients to achieve abstinence (supported by medication to ease the withdrawal symptoms, but not employing the sedation offered by NLC).

While the typical outpatient OST approach substitutes one opioid for another and the typical in-patience approach seeks abstinence, both are normally followed up by a variety of group or one-on-one therapies, of which the most common and longest established is the Minnestosa 12 Step programme (which actually nowadays would more accurately be described as a 6 step programme).  The 12 Step programme is more philosophical than medical, involving self awareness and “recognising a higher power that can give strength”, and most usually involves group sessions. Suffice it to say that the BONDS/NLC protocol is totally different, and offers the patient a scientific/medical solution that is private, comfortable and works vastly better in terms of outcomes within a much shorter timeframe.

What is the average time spent in rehab?

The BONDS Protocol requires a basic inpatient stay of 7 days to achieve abstinence, with some patients electing to stay an extra 7 days if they have particular issues that need additional time to address.  The 12 month aftercare programme does not need to interfere with rest the patient’s life.  Thus a working patient can achieve abstinence and be freed from addiction within the timeframe of a normal annual vacation.  Even more importantly, the relapse rate is extremely low compared with what is achieved elsewhere, especially as far as opioids are concerned.

In other residential addiction rehab clinics, times spent in rehab are typically far longer than they are at NLC.  For most residential clinics the minimum (basic) stay is 4 weeks, but longer stays of 90 days are often recommend.  Outpatient rehab treatment (especially OST) can go on for months. Low success rates and repeated relapses can extend treatment for years.  This typically applies to the treatment of opioid addiction.  For opioid rehab the timescales are mindboggling. Of the 4,736 opioid users newly presented for treatment in 2020/21, 3,081 (65.1%) were still retained in treatment at the end of the period (31/03/2021). 1,067 (22.5%) exited during the year before their treatment was completed, and only 558 (12.4%) exited having completed their treatment. Of the 111,703 opioid patients retained in treatment on 31/03/21, only 2.8% had been newly presented in 2020/21.  29% had been in treatment for over 15 years and 76% had been in treatment for 10 years and more.

For alcohol and drugs other than opioids, NLC offers a short stay with an efficient and comfortable way out of addiction.  For opioid addiction NCL offers a solution to an otherwise hopeless situation.  In spite of the proven successes of The BONDS Protocol from 1996 to 2016 when it was offered under the Detox 5 banner in Harrogate, the accelerated detox that forms part of the BONDS Protocol was never officially encouraged.  Public Health England’s guidelines strongly discouraged “rapid detox”, most probably because PHE and NICE failed to make the distinction between the BONDS sedation technique and the rapid detoxes that are increasingly offered under full anaesthetic in the USA (this type of fully anaesthetised rapid detox is prohibited by NICE in the UK). Instead, PHE favoured OST, in spite of the time and money spent failing to achieve abstinence with this treatment.  Take an example from Bradford City Council. In 2014/15 out of an estimated 4,441 heroin and crack cocaine users 2,674 (60%) were undergoing treatment. Only 6% of the 2,519 undergoing treatment for opioid misuse successfully completed the course. Over a third of those had been in treatment for 6 years or more.

What is the rehab success rate in the UK?

Taken overall, UK addiction treatment has poor success rates, and the outcomes of opioid treatment are disastrous.  This is best illustrated by a chart presented in Public Health England’s 2017 Evidence Based Review:

Trend in proportion of individuals (aged 18 and over) successfully completing treatment by substance 

The situation for opioids has not improved since then:

Public Health England’s 2017 Evidence Based Review seems almost to accept that the low success rates for opioid rehab are inevitable: “There were significant increases in the proportion of individuals (aged 18 and over) leaving successfully for all substance groups between 2007–2008 and 2011–2012. Since then the rates have levelled off, with a decline in the proportion of opioid users completing treatment. This decline is likely to be in part because many of those who now remain in treatment for opioid use are older, often have health and mental health problems and entrenched lifestyles and drug dependence. People using drugs other than opioids have much higher successful completion rates as their use tends to be less entrenched and they frequently have better access to employment, housing and the support of family and friends. It is well established that heroin dependence is often complex and entrenched”.  Comparing the proven 12 month abstinence rate of around 66% for the BONDS Protocol with the dismal numbers shown by PHE emphasizes the need to re-establish the BONDS approach to rehab in the UK and beyond.

The poor results achieved in the UK of course in part reflect the fact that over 95% of addiction sufferers in rehab are being treated in an outpatient or non-residential setting.  It is widely accepted that residential rehab increases the chance of the treatment working successfully for substance addiction rehab in general and for opioid addiction treatment in particular.  So how well does residential rehab actually work?  The answer is that no one really knows.  Although some figures up to the mid 40%’s are cited for overall successful outcomes, no detailed outcome numbers by substance type are published by the mainly private rehab clinics.  It is indeed likely that residential rehab is more successful than outpatient care not least because residential clinics tend to adopt an abstinence based approach rather than OST.  However anecdotal evidence from the medical profession and from health insurers suggest a widespread dissatisfaction with the cost effectiveness of current residential drug addiction rehab, especially as for as opioids are concerned.  

The only thing that is certain is that The BONDS Protocol works far better than other forms of treatment.

What does rehab cost in the UK?

This might look like a simple question but in practice it is difficult to provide a simple answer given the wide range of treatment providers (Local Authorities/NHS, charities and businesses), the different rehab settings (outpatient, residential) the wide range of substances for which rehab is offered and the wide range of rehab formulae (one-on-one vs group, OST vs abstinence etc.).

In considering rehab costs there are a number of sub issues that must be taken into consideration:

  • Cost to whom?: private individual/families, local authorities, charities and charitable donators, health insurers, taxpayers
  • What is the cost effectiveness and value for money?:  it is not helpful just to consider unit costs (e.g. cost per night or per week in residential rehab, cost per session in out patient rehab).  Cost comparisons need to take into account the length of treatment, the outcomes, relapse and readmission rates etc.
  • What is the cost of rehab and treatment compared with the cost of addiction?: for the individual addiction sufferer, the starting point might be to compare the cost of rehab against the cost of feeding the addiction.  For local authorities (and indeed for society and for the taxpayer) there is the wider social cost of addiction including dealing with crime and with the need for social care associated with addiction.

Even to arrive at the basic units costs of rehab is difficult.  How much does it cost to maintain someone on methadone for a year?  Published estimates range from under £1,000 to around £15,000, depending in part what is taken into account.  The situation was probably best summed up a few years back by the former assistant director for health improvement for Stoke-on-Trent.  At that time Stoke had 2,510 heroin users and had to approve a £751,000 cut in its drug and alcohol services.  The council funded methadone prescriptions and ‘supervised consumption’ for around 900 heroin clients. To quote the former assistant director: “There is a general agreement among partners that a direction of travel that leads to recovery and away from a maintenance programme on methadone is the right thing to do.   At the moment we have a very high cost service with, in health terms, very poor outcomes. They’re on a methadone programme.  That means they’re still addicted to heroin, and we’re paying for it. And the costs attached to that are very, very high. We have to pay for the methadone, we have to pay for someone to write that prescription and a pharmacist to dispense it, and it’s hundreds of thousands of pounds.”

Consideration of the social cost of addiction is a bit outside the scope of this piece.  Anyone interested should download that first volume of Dame Carol Black’s Independent Review of Drugs published in February 2020 for the Home Office. She estimates the annual social cost of illegal drug abuse in England is £20 billion.

For the private individual or family, the costs of rehab will depend on:

  • Who provides it.  NHS treatment is free for the patient but may be hard to come by in the current climate
  • Some individuals are covered by health insurance policies that include mental health and addiction. NLC is already registered with Bupa
  • Most individuals seeking residential addiction rehab in the UK will need to do so on a self paying basis.  They will need to evaluate whether to incur such expenditure based on a comparison between the costs of the rehab and the costs of continuing with their addiction.  The costs of addiction of course go well beyond the costs in terms of money.  Quality of life for addicts and their families and the avoidance of criminality are key considerations
  • Having decided to go for rehab, choosing which clinic to attend needs, from a cost point of view, to consider the total cost of the rehab taking into account the projected length of stay (i.e. don’t just look at the cost per day, week or month).  If the treatment is prolonged, will it imply any loss of earnings for those in work?  Key is will be the paying patient’s evaluation of the anticipated value for money: what are to chances of the rehab actually working and relapses and re-admissions being avoided?

For the self payer the costs and value-for-money comparisons will not be easy.   Few clinics provide outcome data by type of substance.  

NLC not only gives reassurances on probable outcomes but also tries to be helpful by publishing its rates.  This this made possible by the finite length of stay (7 days for detox to abstinence) with the option of an additional 7 days if required for any reason.  The other major cost, that of the naltrexone relapse prevention implant or injection, is also a known element:

  • Admissions assessment: £500 
  • Day residential stay and detox: £6,000 (includes assessment fee)
  • Additional week (if required): £5,500
  • Naltrexone implants (normally used for opioids) £7,500 for 12 months protection (includes assessment fee)
  • Naltrexone Injections VivitrolTM (preferred for alcohol and cocaine) £7,980 for a 4 month course
  • Multi-discipline team (MTD) 12 month post detox aftercare and clinical follow-up:  £1,250.

Thus a full programme of NLC treatment costs between £17,000 and £25,000 with excellent outcomes prospects.  When comparing costs with other clinics it is important to probe into the realistic length of stay needed to achieve abstinence and the clinic’s success rates for the specific addiction to be treated.

Who can receive NHS treatment for rehab?

To answer this question it is best to go to the NHS website.  This states:

“If you need treatment for drug addiction, you’re entitled to NHS care in the same way as anyone else who has a health problem. With the right help and support, it’s possible for you to get drug free and stay that way.

Where to get help for drugs

A GP is a good place to start. They can discuss your problems with you and get you into treatment. They may offer you treatment at the practice or refer you to your local drug service. If you’re not comfortable talking to a GP, you can approach your local drug treatment service yourself. Visit the Frank website to find local drug treatment services”.

In practice, the problem with the NHS is availability.  You are very unlikely to find NHS residential addiction rehab, and you have no chance at all unless you live in and area covered by one of the remaining NHS clinics (Bristol, Stoke-on-Trent, Manchester, Maidstone, Liverpool). Otherwise the NHS will offer outpatient rehab.  The picture is particularly discouraging for opioid rehab.  Not only are the outcomes very poor, but the intake figures suggest low availability. In England of the 111,703 opioid patients retained in treatment on 31/03/21, only 2.8% (2,791) had been newly presented in 2020/21.

UK rehab centres: what to look for?

If you decide to go for residential rehab, check first of all whether a clinic offers the type of treatment you feel comfortable with.  Do you want privacy or to share a room? Do you want group or one-to-one therapy?  What level of physical comfort are you looking for?  What are you prepared to go through in terms of withdrawal symptoms, and how does the clinic address your fears?  How long are you prepared to remain in residential care? Above all, what can the clinic tell you about it’s success rates for your specific addiction problem?  These questions should be asked also in the context of the proposed cost of the rehab.

Conclusion

Addiction rehab, and in particular rehab for opioid addiction, is not in a good place in the UK (or indeed anywhere in the world).  In the UK, The BONDS Protocol as administered at The New Life Center, is unique. It should be your first port of call if you are looking for:

  • privacy
  • comfort
  • a short and predicable length of stay
  • detoxification free from withdrawal pain
  • abstinence based detox rather than OST
  • a proven medical and scientific based approach rather than 12 Step
  • proven outcomes that are better than anywhere else, and are way better for opioids.
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