Which ones work best and for who are hotly debated topics. Finding evidence to prove which ones work is difficult. For example, do we judge success by people in treatment completely giving up all drug use or by them moderating their use and being able to better function in their lives? How can the information be found out? Is it good enough to just ask people what they thought of treatment and whether it helped them? And what measures of help should we use? Does it matter whether they stopped or moderated their drug use or whether their health improved? Would they have made changes in their drug use without the treatment?

Research findings

Despite these problems there is evidence that treatment helps people with drug problems. Much of the research is from America. It has found that treatment helps people give up or moderate their drug use and can result in significant reductions in drug-related crime. It has also found that the quicker a person gets treatment the more likely it is they will stay in treatment and that it will be effective.

NICE

The National Institute for Health and Clinical Excellence (NICE) is the body which assesses the research evidence and provides guidance for NHS and other healthcare professionals, commissioners and providers. NICE is unequivocal in its recommendation of all the key aspects of drug treatment, including psychosocial interventions, needle and syringe programmes, and opioid maintenance and detoxification [1-4]. The latest NICE guidelines can be found on their website, http://www.nice.org.uk.

The NICE assessment of the effectiveness and cost-effectiveness of methadone and buprenorphine maintenance therapy for treating opioid dependence is especially striking. TA114 NICE Technology Appraisal Guidance for Methadone and Buprenorphine for the management of opioid dependence, published in January 2007, considered evidence from 31 systematic reviews, as well as a further 27 randomised controlled trials. They found that methadone and buprenorphine treatment results in:

• more people retained in treatment
• lower rates of illicit opioid use
• fewer self-reported adverse events
• people being four times less likely to die
• decreased levels of criminal activity;
• and that the treatment was cost effective.

NTORS

One of the biggest UK studies is the National Treatment Outcome Research Study (NTORS) [5]. Began in 1995, NTORS follows over 1,000 people using a range of hospital, rehabilitation and community-based treatment services. On entry, nearly 90 per of the people were using heroin, 35 per cent crack-cocaine and over 60 per cent were injecting drugs (with a quarter of these sharing injecting equipment with other people). Most had been long term, heavy users.

A year later things had changed and there were clear reductions in the amount of problematic drug use. Abstinence from use of both heroin and crack cocaine had increased significantly. The number of people injecting drugs, or sharing injecting equipment if they still were injecting, had fallen. Even after 4–5 years, the there were marked improvements in drug use. [6]

Big Issue

Another survey was carried out in Liverpool and Manchester by the Big Issue. They interviewed over 550 people who were using drug services. The main conclusion were:

• Most of the drug users were living in poverty and a quarter were homeless.
• A third had been in contact with drug services for more than 5 years.
• Over three quarters who were prescribed methadone were still using street drugs.
• Most of the users received mainly medical interventions but many said they also wanted counselling.
• Many were suspicious of GPs and wanted more community based drug services.

Needle exchange and other support

Research has also consistently found that needle exchanges (where dirty needles and other injecting equipment are exchange for clean equipment), and other forms of support for injecting drug users, reduces needle sharing and the incidence of HIV, the virus that eventually leads to AIDS.

What may affect treatment success?

Clearly living in poverty, having no job, being homeless and having little support from other people is going to limit the possibility of treatment actually working. Unless these underlying problems are tackled, problem drug users will find it very difficult to change their drug use. In addition many treatment agencies are short of cash and have long waiting lists.

Treatment does seem to have a positive impact but questions remain about the most effective forms of treatment for different people and unless wider support is available the effectiveness of treatment will be limited.