What are the solutions for addiction?

Date: 2022-05-05

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

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

Introduction

 Attempts both at curbing substance supply and at reversing addictions have met with far more failure than success right up to 2022.  So are there any solutions?  Tackling addiction can be approached from 2 directions: 

• preventing addiction through legislation, law enforcement, limiting the prescription of opioid painkillers, campaigns promoting sobriety etc.
• treating addiction.

This article deals with the latter, and argues that in a sector where success rates have been inadequate, The BONDS Addiction Treatment Protocol as administered by New Life Center (NLC) offers a rare genuine breakthrough.

What are the solutions for addiction in individuals?

Whether derived from legal or illegal substance consumption, there is a growing acceptance that addiction is a chronic condition that needs treatment more than censure or punishment.  Nonetheless, substance consumption is still often referred to as “substance abuse” and there is no doubt that the social stigma attached to addiction remains a deterrent to seeking help and treatment.

It is therefore important to understand how addiction develops and when the point is reached when escape from addiction becomes extremely difficult without treatment.

Some analysts recognise 4 stages that lead to addiction:

• Stage 1: Experimentation,  defined as the voluntary use of alcohol or drugs without experiencing any negative social or legal consequences.  Consumption usually has the aim of achieving a pleasurable “high”, often in a social context. Some can resist going beyond this stage, but others fail to do so

• Stage 2: Regular Use, when the occasional drink or drug turns into a common occurrence. This can have consequences such as damage to health, driving under the influence etc.  Some can keep it under control.  Others think they can but in truth cannot. Drinking or drug taking on your own is especially dangerous.

• Stage 3: High Risk Use, when substance abuse starts to become dominant, taking priority over other aspects of life

• Stage 4: Addiction, or complete dependency on the substance.  This is typically accompanied by very unpleasant withdrawal symptoms when an addict loses access to the substance or tries to give up. 

Some users will start seeking help before reaching Stage 4, but once Stage 4 is reached it becomes extremely difficult to continue with a normal life or to reverse the addiction without help or treatment.  With drugs, it commonly leads to a life of crime simply to supply the addiction.  As anyone who has lived with an addict knows only too well, one of the worst aspects is the never ending cycle of deception.  To be deceived on a regular basis is just an awful experience.

So Stage 4 addicts need help, but there are all sorts of barriers on their path:

• many are resistant to seeking help, whether through self deception, fear of stigma, or the dread of going through the withdrawal process

• cost and availability.  Free treatment via the NHS is limited and is becoming more so partly because it is funded by cash strapped local authorities.  There is some charity funded care but again availability is limited.  Private addiction treatment is expensive, but this must be compared with the cost of sustaining an addiction.  Only a minority of private health insurance subscribers are covered for addiction

• addiction treatment remains a branch of healthcare with poor and unpredictable success rates, and very poor outcomes indeed where opioid addiction is concerned. NHS outcomes (achieving freedom from dependence) are around 40% for non-opioids and under 5% for opioids. Private clinics generally do not publish outcomes by substance types but anecdotal evidence suggests poor outcomes for opioids. Private treatment is certainly expensive if it doesn’t work.  

So finding solutions for individual addictions is a hit-and-miss affair, and finding a solution for opioid addiction is, frankly, a nightmare. We propose below that anyone seeking treatment for opioid addiction should not hesitate to consider The New Life Centre first.  For non-opioid addictions NLC has so successfully adapted the BONDS Protocol that NLC should always be high on the list of treatment centres to consider.  Unfortunately NLC  will for the time being be out of reach financially for many addiction sufferers, especially given the socio-economic profile of opioid (including heroin and fentanyl) addiction.  But this need not always be the case.  Local authorities and the NHS need to undertake a cost/benefit exercise to determine whether NLC does indeed offer better value for money than paying for treatment that only has a 5% success rate and often involves years of repeated relapses and/or expensively sustaining addicts on opioid substitutes.

Addiction solution options

In considering the solution options available to those trying to escape from addiction, it is in our view necessary to distinction between:

• alcohol, cannabis and cocaine 
• opioids and benzodiazepines.

The former group is easier to treat and in most cases the progression through the stages towards full addiction is more gradual.  Successfully treating the latter group is challenging and trying to withdraw unaided from opioids or benzodiazepines can be risky.

Addiction treatment solutions at home

Since the great majority of addiction sufferers seeking treatment are treated on an outpatient basis, most are based at home during treatment.  At one end of the scale are those who attempt to wean themselves off their addictions on their own or with the support and encouragement of families and friends.  This becomes more and more difficult as they move through the 4 stages of addiction, and is in all probability more difficult for opioids and benzodiazepines than for other forms of addiction.  It should also be borne in mind that more often than not addiction occurs where other mental health problems exist, which can make it yet more difficult for the addict to cope unaided.  While trying to come off an addiction unaided may be courageous, seeking help and/or treatment is in most cases the wisest course of action.

Peer support groups

Joining a peer support group is not the same as seeking professional treatment. Often peer support groups are used by individuals before they reach Stage 4 or seek professional treatment.  Further down the line attending peer support groups can support individuals who are at the same time undergoing professional addiction treatment or therapy on an outpatient basis or after a course of residential treatment.

The best known peer support groups active in the UK are:

• Alcoholics Anonymous (AA)
• Drug Addicts Anonymous (DAA)
• Narcotics Anonymous in the United Kingdom (UKNA).

Their common characteristics are anonymity, non-alignment to any other body, religious groups, and that attendance is free.  AA and DAA both adopt approaches based on the 12 Step Programme (which indeed owes its origins to AA in the 1930s).  UKNA is based more on simple mutual support and experience sharing.

Counselling and Talking Therapies

These tend to form part of many addiction treatment programmes, both residential and non-residential.  They may comprise group sessions or one-to-one counselling.  Sometimes they follow on from detoxification, or they may form the main element of the treatment where medication assisted detox is not deemed necessary or appropriate.  They may form part of a treatment programme that is based on the 12-Step approach. A vast range of therapies are in use, going well beyond simple talking therapies, for example

• Cognitive behaviour therapy (CBT)
• Mindulf based cognitive therapty (MBCT)
• Dialectical behavioral therapy (DBT)
• Acceptance and commitment therapy (ACT)
• Psychodynamic therapy
• Psychosexual therapy 
• Family therapy
• Trauma-focused therapy including eye movement desensitization and reprocessing (EMDR)
• Other complementary type therapies including, art and music, drumming, psychodrama, horticultural and equine-assisted therapy to name a few
• Fitness, massage, acupuncture, and aromatherapy
• Creative workshops
• Yoga and mindfulness meditation
• Contingency Management (see below).

Contingency Management

Contingency management refers to a type of behavioural therapy in which individuals are ‘reinforced’, or rewarded, for evidence of positive behavioural change. These interventions have been widely tested and evaluated in the context of substance misuse treatment, and they most often involve provision of monetary-based reinforcers for submission of drug-negative urine specimens. The reinforcers typically consist of vouchers exchangeable for retail goods and services or the opportunity to win prizes. Although contingency management has a great deal of evidence supporting its efficacy, and the UK National Institute for Health and Clinical Excellence guidelines recommend its use, few psychiatrists and other mental health professionals are familiar with these interventions, and even fewer implement contingency management in their practice.  It does not form part of the BONDS Protocol/NLC programme.

12 Step Programmes

12 Step programmes probably represent the most widely used approach to addiction treatment in the UK and worldwide.  12 Step was the original basis of Alcoholics Anonymous, founded in Ohio in 1935.  The 12 Steps represent a progressive submission to a higher power and to the will of God. 

It is the basis of treatment in many addiction treatment facilities, both outpatient and residential.  Amongst the residential clinics in the UK using 12-Step are The Priory, Castle Craig, and UKAT.  The peer support groups AA and DAA still use it. While it clearly has a religious orientation, in general the religious belief is not a condition of participation although it does seem to apply the acceptance of a higher power.  Whilst this type of approach is clearly important as it is easily accessible via peer support groups and is perhaps more suitable for some than others, long term abstinence based outcomes for some substances such as opioids are questionable.  As the BONDS protocol is driven by its abstinence outcomes via a very structured one to one bio/psycho/social treatment model, it is one of the few providers that does not directly adopt the 12 step programme but work with other organisations that may use the 12 step approach to support a personalised relapse prevention programme

Detox and Medication Assisted Therapy solutions for addiction

While 12 Step owes its origins to the treatment of alcoholism and has become adopted as an approach to drug addiction treatment, for detox and medicated assisted therapy it is probably best to start with opioid addiction treatment and work out from there.  This is because withdrawal from Stage 4 opioid or benzodiazepine addiction is so traumatic, painful and feared that detoxification is difficult to achieve without some form of medication.

For opioid detoxification there are two fundamentally different approaches:

• Opioid Substitution Treatment (OST) which seeks to substitute illegal opioids (e.g. heroin) or abused (and often illegal obtained) prescription opioids (e.g. Tramadol, Oxycontin and other oxycodone, fentanyl, morphine, codeine) with legally supplied opioid substitutes (e.g. methadone or buprenorphine), and then progressively wean the patient off the substitute, often using 12 Step and/or other therapies in support
• Medication assisted detoxification that aims for full abstinence once the detoxification process is completed.  Here, 12 Step or other therapies and counselling are usually employed post detoxification to discourage relapse.

 OST is used in both inpatient and outpatient treatment (and in some charitable residential clinics) while abstinence based detox tends to be used exclusively in residential facilities.

Looking specifically at abstinence based detoxification, in the UK inpatient detoxification takes place with the patient conscious, but selected non-addictive medications are administered to reduce the painful withdrawal symptoms.

In the USA, as an alternative to medication assisted detox, at least 7 residential clinics have opted for “rapid detox”. In most cases, the patient is fully anaesthetised (often in a hospital).  It remains controversial, partly because there were some deaths in the early days, but it has strong advocates, who consider that the small risks are far outweighed by the >100,000 deaths are year from opioid overdoses in the USA.

Such fully anaesthetised detoxification is banned by NICE in the UK, and indeed the BONDS/NLC team is strongly opposed to it.  However there is a middle way, in which the patient is partially sedated but not fully anaesthetised (semi wakeful sedation with no intravenous medication involved) allowing for a virtually pain free accelerated detoxification in about 4 days, safely achieving full abstinence.  This is the approach of BONDS/NLC.  There is one chain of clinics offering the same in the USA and one in Western Australia, but both these provide a less comfortable experience than NLC, putting them up in a local hotel rather than in a residential clinic.  All three, NLC included, offer Naltrexone for relapse prevention.

How long does it take for addiction solutions to be successful?

To start with, a great deal of addiction treatment is simply not successful based on the criteria that would be used for most other medical treatments.  This is true in particular of opioid addiction treatment, except in the case of BONDS/NLC.

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, thanks to the use of Naltrexone, 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 the standard recommended length of stay is 90 days.  Outpatient rehab treatment (especially methadone based 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.

These long periods spent in treatment include many cases of multiple relapses and readmissions.

Which are the most successful solutions for addiction?

Leaving aside BONDS/NLC for the moment, the most honest answer to this question is that we simply don’t know.  The detailed monitoring outcomes of addiction treatment is notoriously lacking in the UK and worldwide.

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 (PHE) 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:

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 without solid relapse prevention strategies offered.  It is widely accepted that residential rehab increases the chance of the treatment working successfully for substance addictions in general and for opioid addiction 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. 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 PHE analysis is not broken down by type of setting or type of treatment.  Some private clinics give indications of overall success rates but do not publish their outcomes for specific addictions. Thus if you are an opioid addict seeking treatment, it is difficult to find out who offers the best hope of a successful outcome. 

The only thing that is certain is that for opioids The BONDS Protocol works far better than other forms of treatment.  The experience gained from opioids and transferred to the treatment of other addictions makes NLC the safest bet for any addiction treatment.

Drug rehab does not end with detox. Not only does NLC offer the most reliable and comfortable form of detox, but it also far exceeds other treatments when it comes to relapse prevention.  The low overall success for sustained opioid abstinence combined with the prevalence of the 12 Step approach suggests that the scientific medical solution to relapse prevention offered by naltrexone far out performs the vague and outdated appeal to a higher power that forms the basis of 12 Step, although, support groups that adopt the 12 Step programme can still compliment NLCs relapse prevention programme.

How much does it cost to successfully treat an individual’s addiction?

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 number of different substances for which rehab is offered and the wide range of rehab formulae (one-on-one vs group, OST vs abstinence etc.).

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.  
• Having decided to go for rehab, choosing which clinic to attend needs, from a cost point of view, to take into consideration the total cost of the rehab bearing in mind 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:

• Admissions assessment: £500 
• First week detox: £6,000 (including assessment fee)
• Additional week (if required): £5,500
• Naltrexone implants ( for opioids) £7,500 for 12 months protection (includes assessment fee); 
• Naltrexone injections Vivitrol^TM (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 compared with £££ for a competitor with much poorer outcomes 

Which is the best solution for addiction for me?

Again the lack of detailed outcomes data makes this a difficult question to answer.  The simple answer is that for opioid addiction treatment The New Life Centre is in a class of its own.  Not only is it excellent in absolute terms, it is head and shoulders above the rest in a sector that currently is simply inadequate.  NCL is also almost certainly the best choice for other forms of addiction, although the differences may be less stark when comparing with the best of the other clinics, especially for alcohol.

The problem of course is that as of now the capacity at NLC is limited, and the cost may be out of reach for a lot of people addicted to opioids. Indeed, most heroin addicts may not be in a position to pay for treatment at all.

The NLC however, wants and needs to be available for all and will be expanding and looking to offer NHS funded beds in due course.  For the time being however, sufferers who feel they cannot afford to pay for treatment are still better off seeking assistance from the NHS.  Though the NHS has precious little by way of inpatient capacity, it has a wide network of drug intervention facilities staffed with medical professionals that can help start the recovery process.

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.

What are the solutions for addiction in society at large?

Phase 2 of Dame Carol Black’s Independent Review for The Home Office (July 2021) looked at this question and came to the following conclusions as far as treatment is concerned:

“Local authorities are responsible for drug treatment. Spending on treatment has recently reduced significantly because local government budgets have been squeezed and central government funding and oversight have fallen away. We have concluded, based on current evidence of prevalence, that an additional £552 million is needed from DHSC by year 5 on top of the baseline annual expenditure of £680 million from the public health grant, to provide a full range of high-quality drug treatment and recovery services, as follows:

year 1: £119 million

year 2: £231 million

year 3: £396 million

year 4: £484 million

year 5: £552 million.”

On rebuilding treatment services the report states:

“Local authorities should commission a full range of evidence-based harm reduction and treatment services to meet the needs of their local population. However, some services have all but disappeared and will not automatically return even with higher funding and better commissioning. High cost but low volume services, such as inpatient detoxification, are too costly for a single local authority to procure and should be covered by a new regional or sub-regional approach to commissioning”.

“Too many people with addictions are cycling in and out of prison, without achieving rehabilitation or recovery. The recent sentencing white paper committed to greater use of police diversions and community sentences with treatment as an alternative to custody. This must now be put into action, alongside extra funding for treatment places to accommodate the extra demand”.

“Research in many areas of addiction is underdeveloped and under-resourced, with the exception of opioid substitution treatment. The research infrastructure in local authorities is far less developed than it is within the NHS, and current service models often do not provide the stability, expertise or right staff mix to undertake high quality research. We recommend that DHSC and the Department for Business, Energy & Industrial Strategy (BEIS) encourage and facilitate research into what works to combat substance misuse, across supply, prevention, treatment and recovery. DHSC should promote innovative research on addiction and its implementation in practice by offering incentives or rewards to companies and other organisations for effective developments in this field. For example, pharmaceutical advances”.

“We recommend that DHSC, NHSE and the Office for Health Promotion review by the end of 2021 to 2022 the commissioning and funding mechanisms for high-cost but low-volume services such as inpatient detoxification and residential rehabilitation. DHSC should introduce a regional or subregional approach to commissioning these services to ensure national coverage”.

On December 6^th 2021, following the publication of the Dame Carol Black report Phase Two, the Government announced proposed revisions to its approach to the war on drugs, overhauling the drug recovery and treatment system. The government says it is to provide rehabilitation for 300,000 drug users who carry out half of all shop thefts, robberies and burglaries. Ministers have announced that a 10-year drugs strategy will allocate £780m in funding for the drug treatment system in England. All local authorities in England will receive new money for treatment and recovery – with the 50 councils where there is most need receiving the funds first. The strategy, say ministers, will treat addiction as a chronic health condition in order to reduce stigma, save lives and break the cycle of crime fuelled by addiction.

Interviewed by Andrew Marr on the BBC on December 5^th 2021, The Justice Secretary Dominic Raab suggested that a shift from OST to abstinence based treatment might be encouraged, but this has not been widely reported elsewhere.

What is really needed is a full cost benefit analysis for progressively moving opioid addiction treatment from a model that delivers a success rate of <5% to one that actually works, adopting the BONDS Protocol to serve the mainstream of opioid addiction.

Conclusion

Addiction treatment is in a poor state and opioid addiction treatment is wholly inadequate,  OST and 12 Step do not produce the outcomes required successfully to fight addiction alone.  The BONDS Protocol as practised at The New Life Centre opens up the possibility of a breakthrough, but is currently within the reach of only a tiny proportion of the addicted population.  Ways must be found to make it widely available to the through the NHS, above all for those addicted to opioids.