NICE Guidelines – Rehab Benefits the Most Severely Affected

Only around 2% of people in active addiction treatment will get access to residential rehabilitation services. In some areas that figure will be even less. Over the last decade there has been a definite policy of restricting access to residential rehab by the health and social services in the United Kingdom. In cases where residential rehab is offered, it tends to be seen as a “last resort” treatment. This policy is seen to be endorsed by Britain’s National Institute for Health and Clinical Excellence (NICE).

Mike Ashton, editor of the Drug and Alcohol Findings Effectiveness Bank, and Dominic McCann, Head of Development at Castle Craig, will present their differing views.

This week we hear from Mike Ashton:

“Commissioners who insist residential care should be a last resort can and do claim the authority of Britain’s National Institute for Health and Clinical Excellence. NICE‘s experts advised that residential treatment be reserved for substance users with “significant comorbid physical, mental health or social (for example, housing) problems”, who should have “not benefited from previous community-based psychosocial treatment”…  NICE’s advice was based on not even a handful of studies that recorded no overall advantage for residential care over alternatives.

Critics of NICE’s ‘last resort’ position argue that the reason why some clients are in such poor mental, physical and/or social states is that residential rehabilitation had been denied them earlier in their drug using careers when they had a greater chance of succeeding before the deterioration became too deep. The opposing argument is that trying residential services first risks unnecessary expenditure which drains treatment resources because it is impossible to predict with any certainty who will do well and who badly after their spell at the rehabilitation centre.

Most influential among the studies reviewed for NICE was a randomised comparison of a day versus residential therapeutic community for US crack users. It found no lasting anti-relapse benefits from the residential setting but – as in several other trials – the researchers had to limit the severity of their subjects so that all could safely be sent to either residential or non-residential care. The result was that nearly three quarters of potential participants could not join the study, and those who could were the ones least likely to need and differentially benefit from residential care.

A contrary line of argument is that non-residential rehabilitation in the area where the client is going to have to live may be harder, but also more realistic and more likely to stick than ‘recovery’ achieved in a protected environment far removed from the temptations and pressures which helped sustain the client’s addiction. Contenders on this side of the argument can cite William White, US guru of re-orienting treatment and allied systems to recovery objectives and principles. In one of his key work he points out that the non-recovery oriented systems he seeks to transform “grew out of a tradition of isolating addicted persons from their natural physical and social environments [to] enter a closed therapeutic environment” such as a residential treatment programme or therapeutic community.

The problem as he sees it that learning to live without drugs there is likely to be unlearnt on transfer to a different environment: “The greater the physical, psychological, social, and cultural distance between the treatment environment and the natural environment of the client, the greater will be this transfer-of-learning challenge.” Part of the solution, he argues, is a “greater emphasis on delivering home- and neighborhood-based (eg, health clinics, neighbourhood centers) addiction treatment and recovery support services” – the antithesis to the traditional model of residential rehabilitation in Britain.    

No conclusive answer to the residential v. non-residential question can be found. Non-randomised studies are generally confounded by differences between clients who find their way to residential services, and those who do not, while randomised studies can only ethically include people who will accept and can safely be allocated to either. Not surprisingly, they also tend to do equally well in either. Our reading of the research is that while non-residential care is sufficient for many clients, residential care has particular benefits for the minority who are most severely affected.”

Mike Ashton’s contribution is based on the Effectiveness Bank hot topic entry, Residential rehabilitation: the high road to recovery? Mike Ashton invites you to see what the researchers have discovered by running this search on the Effectiveness Bank site, but reminds you that no conclusive answer to the residential v. non-residential question can be found.