Local substance misuse services or national everything services

Whether it’s in relation to alcohol or opioid treatment, I’ve been thinking a lot recently about how people might need support specifically in relation to certain substances (as opposed to ‘substance use disorders’ or wider issues related to health or social care).  That sounds a bit cryptic, so let me try to explain.

As usual with this blog, it’s not an original or mind-blowing insight, but something that keeps occurring to me that I think we should remind ourselves of more often.

When we discuss treatment or policy, we often do this by substance.  So there’s been discussions of alcohol labelling recently, and a growth in personal testimonies of how giving up alcohol makes people fitter, happier and more productive (recently Megan Montague’s Sober Story caught my eye).  And there’s discussions locally and nationally of how we can specifically improve opioid substitution treatment (OST).

But as we know, if ‘addiction’ is anything, it’s about more than a substance.  It’s about all those things we label ‘recovery capital’ – health, housing, employment, relationships, etc – whether for good or bad.  To a certain extent, substance use becomes a ‘substance use disorder’ when it starts to have negative effects on other aspects of a person’s life.

And so it’s unsurprising that people find it hardest to change their patterns of substance use when the challenges they’re facing – and their reasons for using – are not just about the substance.  It’s people with the least severe issues for whom the substance is the primary problem, and it’s these people who are best served by interventions that focus on the substance itself – like alcohol brief interventions.

And yet when we talk about treatment services, we’re generally thinking of things that are designed for those most in need of support.  We know that most people ‘spontaneously recover’ without formal support, as a result of their own thinking and support from friends, family and the wider community.

And yet the services we provide – which should be replicating those supporting factors like employment, housing, family, community – are typically labelled ‘drug’ and/or ‘alcohol’ treatment services.  In fact it’s not just that they’re labelled in this way; we commission and provide them separately from housing, employment, and other health and social care services.

This doesn’t make sense to me.  And in conversations and meetings over the past few months and years I’m encouraged by the fact it doesn’t seem to make sense to anyone.  I’ve written before about how substance misuse treatment can feel neither part of the ‘health family’ or social care and other related services, and given the cross-cutting nature of these issues there’s no point in searching for the ideal institutional ‘home’ for this agenda.  But equally, it’s inefficient (and exhausting) for local areas to be reinventing the wheel, and I think there are some structural and policy changes that could make this easier.

This doesn’t just mean devolution of budgets, though that might make collaborative work easier.  I still don’t think there’s a magical solution, and the key is to get relevant people to work together better at a local level – not just on the frontline, but in linking policies and planning.

This isn’t an endorsement of localism, though.  Without some form of external prompt, when we’re under pressure we often have a default of ‘tending our own garden’.  It can seem not just comforting but a priority to focus on what we can control ourselves and JFDI if we want to make a genuine difference.

The problem is that this isn’t the most efficient way to deliver support to the people we’re most concerned about.  There is a role for national organisations like PHE to be that voice reminding us to look up and think about the bigger picture.  Actually, it needs more than just a voice.  Recommendations are often disregarded, or considered to be stating the obvious – even if they’re equally obviously unachievable.  Requirements, from an agency with teeth, can drive these conversations, particularly in the areas where collaboration is most challenging.

In searching back through this blog to see when I’ve written about this before, I notice a striking, brief piece from several years ago.  Nothing has changed as yet, but the sheer weight of reports and recommendations from organisations like the ACMD do genuinely seem to be making a difference.  More and more people seem to be agreeing with the idea that strengthening national guidance and oversight (even commissioning at a national level) would be a step forward, and I get the feeling that key people with influence at a national level are taking this on board.  Here’s hoping.