25 August 2010

So This is What a Sucessful Policy on Cannabis Looks Like!

The ACPO report on Cannabis Policing "Three Years On" makes depressing reading. It looks at the way that the UK cultivation of cannabis has changed over the past three years and should represent compulsory reading for anyone who believes that the prohibition of cannabis has been a success. These developments over the past three years, considered alongside the developments over the past thirty plus years, highlight just what a disaster the prohibition of cannabis within the Misuse of Drugs Act (and before that the Dangerous Drugs Act) has been. The policy has seen:
  • between 1974 and 2002 there was a ten-fold increase in people found guilty or cautioned for cannabis offences (1)
  • increase in levels of cannabis use in the UK which have only recently dropped off slightly since their reported peak in the mid 90s;(2)
  • a drop in the age of onset of cannabis use; (3)
  • increased potency in terms of THC levels (4)
  • the emergence of imbalanced forms of cannabis containing high levels of THC and minimal levels of CBD (5)
  • concentration of cannabis production in the hands of criminal gangs who are also involved in other drugs, people traficking, weapons, counterfeiting and other offences;
  • yearly increases in number and quantity of cannabis seizures but without a significant impact on the availability of cannabis in the UK (6)

By any measure, it is hard to view as a success a strategy of prohibition that has seen the substance being controlled become more potent and less safe, be used more widely, by younger people, despite a non-stop policy of crop and drug seizure, arrest and criminalisation of users and producers.

The evidence from the ACPO report on cannabis production is the latest evidence that in addition to prohibition acting as a driver for less safe, unregulated cannabis markets, prohibition and the profits associated with it have concentrated the production and distribution of cannabis in the hands of a smaller number of large producers, controlling the market with increased force, and with crossover to other offending.

Historically, before gaining power, both David Cameron and the Liberal Democrats wanted to reform the law on cannabis. David Cameron, who it is widely accepted had dalliances with at least one controlled drug when younger, endorsed the moving of cannabis from Class B to Class C. Once elected leader of the conservative party is belief in evidence based policy seemed to evaporate and argued instead for Cannabis to return to Class B.

The Liberal Democrat policy historically was for radical reform of drugs legislation, and in terms of cannabis proposed "adopting a policy of not prosecuting possession for own use, social supply to adults or cultivation of cannabis plants for own use." (7)

However, since entering the ConDem coallition, the Liberal Democrats have been silent on this subject, and it will not be a suprise if, when the Government drug strategy is published in October, all mention of cannabis reform is lost.

But even the Liberal Democrat's old, relatively progressive stance is inadequate and by leaving production and supply in an unregulated market, perpetuates the problems in terms of criminal production, unregulated strength and unmanaged supply.

Given the ongoing disaster of cannabis prohibition the need for Government to fully revise the laws on cannabis are long overdue. Cannabis needs to be licensed and regulated to make it safer. Features of a regulated cannabis market would include:

  • licensed, registered outlets with staff who receive training on cannabis use and risks
  • age-restricted sales to people aged over 18 only
  • sliding bracket of taxation on retailed cannabis with higher strength products being taxed at a higher level;
  • products labelled to indicate THC and CBD content, with appropriate health messages
  • taxation from cannabis sales ring-fenced to fund awareness and treatment interventions
  • personal possession of up to three cannabis plants, by persons over 18 no longer a criminal offence
  • licence production in UK and overseas, to encourage (for example) Afghani opium producers to produce hashish not heroin.

Given the current resurgent abstentionist climate, the puritanical approach of the Conservatives to drugs, and the apparent willingness of the Liberal Democrats to trade belief for power, it is vanishingly unlikely that any changes will be forthcoming. So in the meantime, it is back to the prohibition hole and time to keep digging. Sanity, anyone?

23 August 2010

The Straw Man of Recovery

The Times today reports that The Home Office will be pushing ahead with a drug strategy focussed on achieving abstinence from both illicit controlled drugs and prescribed substitutes. The article also reinforces the impression that the strategy will include payment by results and that it may include coercive measures like removal of benefits.

The Times' article doesn't offer any substantive new evidence for this. There has already been a significant amount of information (e.g. the NTA business plan, comments from Cameron et al, and the consultation on the Drug Strategy) which strongly indicate the direction of travel.

The Conservative predilection for abstinence-based interventions should come as no suprise. Nor should the threat of coercive measures.

The real icing on the cake though, has been the idea that abstinence is readily achievable. This is where the newly vocal and high profile neo-abstentionists in the Recovery movement have been so successful. A core message that has been promulgated in a number of forums is the idea that the treatment of people with drug dependency is a conspiracy primarily cooked up by pharmaceutical companies and drugs workers out of some sort of self interest. This straw man, as repeatedly offered on recovery forums suggests:

- that a key driver for the ongoing prescribing of methadone is the financial interests of the manufacturers of methadone;

- that drugs workers don't really want to assist people to end their drug use because either (a) they don't believe people can stop or (b) they don't want people to stop because they will lose their jobs

- that the combination of medical dogma, professional self interest and big-pharma is active in keeping people in addiction.

Having created this simplistic model, the argument seems to then extend - these services and structures are a barrier to recovery and by sweeping these away and replacing them with user-led, recovery focussed projects drug users will see the recovery of others, be "infected" by the contagion of recovery and then learn from others how to live productive drug free lives.

It's a very simple and very seductive message. And it has found a ready ear with the Conservatives who are using the recovery mood music to say that the previous Government merely offered substitution not freedom and for the first time this Government will offer true Recovery.

Ignore the history - that the earliest drug treatment services in the UK were mostly established by ex-users in recovery themselves - and while they successfully helped some people they were not a panacea for all. Ignore the fact that the UK drug field has a significant number of people with histories of dependency who can and do believe and know that people can achieve lasting recovery, sometimes with medication, sometimes without. The idea that drugs workers want to keep people addicted for their salary is a vicious lie.

Ignore the practicalities - that payment by results will disadvantage small and independent charities and start ups who can't afford the overheads.

Ignore the safety considerations - that supervisory frameworks from, for example the Care Standards Commission helped ensure minimum levels of safety in residential treatment. Remember that not every residential drug service offers or offered a safe, therapeutic or high quality service and stripping away safeguards leaves the most vulnerable at risk;

Ignore the casualties - that on the one hand reduced, time-limited abstinence driven models will assuredly deliver a larger number of people who are drug free at the end of treatment (and this will be the measured success) but there will be the people who are driven out of or drop out of treatment, some of whom will die. They will not be a measure of success.

Ignore the lost - the people who will lose their benefit, lose their housing, their medical care and their toe-hold in society. Forget that the route back to recovery for these people will be that much harder and some won't make it. Except of course unless you believe in a Jellinek-type model where people have to hit rock-bottom before they will turn to recovery;

Ignore the inconsistencies: that some people will consider Treatment a "failure" if the person has stopped using heroin and crack but continues to use cannabis, even if this is under control. Abstinent from what - and by whose standards? Addiction Today's?

Ignore the cost: the DCLG proposes cutting costs by up to 40% and this will affect budgets including Supporting People - which does a huge amount to help people with drug and alcohol problems secure housing and sustain independent living. The work of some residential social landlords to support people with drug problems has been a shuge success story in some parts of the country. The feared cuts to SP money will destroy this work. And trying to help people with drug problems sustain change without housing is a fools errand.

But hey, who needs these petty problems. Just bathe in the mood music from the Recovery Community and ignore the real-politick of the situation. and when it all comes crashing down make sure that the people who are held to account are not just the policiticians who introduced the policy, but also the neo-abstentionists whose evangelism is rapidly becoming the new dogma.

20 August 2010

Something wicked this way comes…

The proposals by Kit Malthouse, Deputy Mayor of London for a new and robust approach to sobriety enforcement for problem drinkers was reported in the media but has received little comment.

The model promoted by Malthouse is based on a scheme in the States. I remember first becoming aware of it during an episode of CSI Miami which featured an alcohol-detecting leg bracelet, which would identify if the wearer had consumed alcohol, and automatically send a message (e.g. to a Blackberry) informing authorities that the wearer had consumed alcohol, where, and when.

A quick search highlighted that not only did the technology exist, but it was being used extensively. The SCRAM system States including Florida, South Dakota and Michigan were amongst those in the US adopting the technology which came to market in 2003.

Malthouse proposed a system of punitive enforcement of abstinence. His model included:
- a sobriety requirement
- 24 hour incarceration for people breaching the requirement, as evidenced by the detection tag
- self-financing by people required to take part in the scheme.

The proposals as outlined by Malthouse couldn’t come in to power as outlined – they would need legislative changes that, fortunately, fall outside the powers of either the London Assembly or the Metropolitan Police. While ‘alcohol asbos’ introduced in August 2009 can impose restrictions on buying alcohol or drinking in public, they don’t enforce sobriety and as such wouldn’t as they currently stand be suitable for Malthouse’s plans.

Likewise Drug Abstinence orders, as they currently stand, relate only to Class A drugs and so wouldn’t fit with Kit’s ideas.

The use of alcohol-detection bracelet systems in the UK hasn’t yet been approved. This, however, is probably less of an obstacle. The use of drug-testing equipment is a growing and hugely lucrative business and there is every reason to believe that a constant testing system which is worn by users will be adopted at some stage in the UK.

At this stage, the system detects ethanol excreted through the skin, but does not work with other drugs. The Guardian article reports “The structure of the programme is being adapted to include drug abusers,” but at this time there have been no announcements that the technology has been successfully adapted to detect drugs of abuse transdermally. While ion-track technology (e.g. Itemizer machines) can indicate contact with controlled drugs, this is markedly different to proving intake, which, at this time requires more invasive procedures such as oral swabs, blood or urine testing. Even the most recent developments, such as proposed roadside drug-driving tests are based on saliva testing.

But it is the third aspect of Malthouse’s proposals which are the most interesting and should ring the most alarm bells – the adoption of “offender pay” systems in the UK. A number of US states, including Indiana, Oregon and Texas have adopted some elements of an “offender pays” system whereby a proportion of the subjects earnings are deducted to pay for the cost of alcohol monitoring units, and associated staff costs.

The costs of these are typically applied on a sliding scale depending on earnings, but in most situations allow the scheme not only to break even, but even generate a small return.

And this is the point where the schemes become most worrying – because they create an incentive firstly to get more people on the scheme and secondly to keep them on the scheme. One hundred people on the scheme, each generating a $5 surplus per day for the scheme - $182,000 a year.

It is easy to see the appeal of introducing offender-pay schemes in the UK – especially when we have seen proposed cuts to the Department of Justice which will radically affect the management of offenders in the community.

Although Malthouse may be keen to take forward measures such as these radical plans for tackling alcohol-related disorder, he can’t do it without the support of the Government. While Boris and Malthouse may have effectively gained political control over the Metropolitan Police, even this won’t give them the resources and legal powers required for such a change of offender management. What will be critical is how much power and influence Boris and Malthouse have within the coalition Government and the extent to which policies which fall further to the right will find a willing ear at least for pilot programmes within the capital.

17 August 2010

If I can’t dance I don’t want to be in your Big Society.

This blog probably shouldn’t really start with a misquote of something that Emma Goldman never said. Instead it would have been better to start with Milan Kundera from the Unbearable Lightness of Being: “The struggle of man against power is the struggle of memory against forgetting.”Since the advent of the Coalition Government the media and numerous groups and individuals seem to be engaged in an orgy of forgetting, especially when it comes to the analysis of the putative “Big Society.”

Roll back twenty years when to the advent of John Major’s Conservative Government. We saw the development of an astonishing array of small, grass-roots initiatives set up. There was creative use of abandoned buildings. Land that had been abandoned by industry was used for cultivation, to produce locally grown vegetables for communities. Initiatives to protect local assets such as woodland gained profile. Self managed, self-funded and self-policed recreational activities became more widespread across the UK.

But these initiatives were not heralded as an example of an embryonic “Big Society.” It became known as DIY-culture and unfortunately it did not fit with other aspects of Conservative Ideology.The use of derelict land or empty buildings ran counter to Conservative views of land and property ownership and so they passed laws to make it easier to clear the occupiers off that land and from those buildings. Autonomous cafes, galleries and community spaces were established and briefly thrived, then closed by Police and Bailiffs.

The importance of industry and cars was rated higher at a national level was considered far more important than the views of local residents and communities, so bypasses were authorised by the Government despite local opinion and protests. The Government purchased an independent, unaccountable security force using commercial agencies such as Reliance to deliver this agenda.

The proliferation of the “Free-party” movement, its association with controlled drug use and the non-approved use of land for such parties again ran counter to Conservative values and culminated in the end in the much-loathed Police and Criminal Justice Act being passed in 1994. It was the death knell of this period of DIY-culture in the UK.

So does Cameron’s much-discussed “Big Society” share common cause with DIY culture? The answer to this has to be a resounding “no!” The Big Society is a straight Thatcherite agenda presaged in Thatcher’s much misquoted line saying “there is no such thing as society.” Her wider comment at the time shows the continuity from her views to those of Cameron: “There is no such thing as society. There is living tapestry of men and women and people and the beauty of that tapestry and the quality of our lives will depend upon how much each of us is prepared to take responsibility for ourselves and each of us prepared to turn round and help by our own efforts those who are unfortunate.” http://www.margaretthatcher.org/document/106689

And herein lies the problem; the Big Society as proposed is inherently Conservative. It is attempting to create and engender a conservative model of society, seed-funded and driven from the top and delivered from the bottom.

Provided that the hopes, dreams and aspirations of a community fit in to this Conservative ideological world-view, then the Big Society will serve you well. But for those who fall outside it, then there’s no place for you in this Society.Look at some of the examples that have been cited as examples of the “Big Society.” The reduction in sex work in Birmingham’s Balsall Heath is held up as one such example.

What the example as cited neglects to mention is that alongside the passive recording of kerb-crawlers, local activists also allegedly threatened and harassed women involved in sex work – a house was fire-bombed, windows had bricks thrown through them, and women believed to be prostitutes were sent poison pen letters by local activists. So it’s a Big Society that fetes you if you want to set up a self-policing vigilante movement that removes kerb-crawlers and sex work from a community. But take this specific issue a little further. What if a local community, in a fit of pragmatic liberalism, decided that the best way forward was rather than simply trying to wish the problem away. If this grassroots, locally agreed, locally relevant initiative approach were mooted, what would Cameron say then? Would it be embraced within the Big Society as an example of local empowerment. Or would it be stamped out as not really the sort of Big Society we want. There is evidence, such as models of tolerance that were trialled in Edinburgh, that show tolerance models can result in a marked reduction in attacks on sex workers.

David Cameron signalled a desire to review the laws around prostitution in the UK, following the murder of three women in Bradford. But if he decided against full legalisation or tolerance zones, what then for a local community wanted to pursue such a route?

And what of drugs (for this is, if nothing else, a drug-focussed blogging site)? What would the Government do if a local authority, in conjunction with the local police and local community, decided that a supervised drug consumption room was the most sensible response to the issue of public drug use? Would this be something that would be resourced and funded by the Big Society Bank? Would it receive the endorsement of the Government as an example of local solutions for local problems. Or will it be given a firm “red light” from Number 10, as has previously been the case. This is an especially loaded issue as, when he was part of the 2002 Home Affairs Select Committee, Cameron came out in favour of drug consumption rooms. The report unequivocally demanded that “…an evaluated pilot programme of safe injecting houses for [illicit] heroin users is established without delay…”

It would be an interesting test of integrity to see what would happen if a local area trialled such an approach now. Would David Cameron support such a move in practice, as he did in theory in 2002. And would such a thing be tolerated within the Big Society.If it does then the Big Society could genuinely be something inclusive. It could represent a tolerant, informed, flexible and liberal model of community empowerment. But if this isn’t the case, and such approaches are blocked by Central Government then this isn’t such a big society after all. It’s the same conservative view of Society that crushed the DIY Culture almost twenty years ago. It’s learned a new language and it’s changed its clothes, but it still won’t be a revolution that everyone can dance to.

10 August 2010

Cannabis: B but no PND says the Met PC

It's just got more confusing on the cannabis front. The Metropolitan Police is reported to be abandoning the use of Penalty Notices for Disorder (PNDs) in a number of London Boroughs. This was reported in the Evening Standard and then on the BBC.

These powers had been used for a number of offences such as shoplifting and drunken behaviour. But the use with which we are interested here is there use for second offences for cannabis possession.

The current ACPO guidelines on handling cannabis possession, since cannabis moved back to Class B, was that for a first offence, the person should be given a "cannabis warning." As part of an escalating series of responses, second cannabis offences aren't meant to be given a cannabis warning but should have resulted in a Penalty Notice for Disorder. A third offence would then mean arrest and charge, and a resultant criminal record.

It is not immediately clear if the decision to abandon PNDs will extend to cannabis enforcement. If it does, the decision could be good news or bad news as regards cannabis enforcement (depending of course on your point of view).

The BBC reported a Met Police spokersperson as saying "We are seeing if there is a more effective way to deal with them, such as through cautions, through the courts or, in minor cases, words of advice."

Given that cannabis users already receive "words of advice" in the form of cannabis warnings already, it doesn't seem likely that further "words of advice" will be offered to people repeatedly found with cannabis. So it seems more than likely that for second and subsequent offences, arrest and charge, and court action look more likely.

We have written to ACPO to seek clarification on this important issue. more news as it happens

08 August 2010

Please look after these drug services!

With the LibCons embarked on a whole scale razing of 'that which went before,' huge swathes of health-care are set to be restructured. Proposals in the White Paper have already been made including proposals to:

  • dismantle Primary Care Trusts (PCTs) and Strategic Health Authorities (SHAs)
  • abolish the National Treatment Agency
  • abolish the Health Promotion Agency
  • establish a national Public Health Service, with Local Authority planning and delivery under local Directors of Public Health
  • Increase the role of GP Consortia in commissioning services.

At this stage, details are scanty. Details, for example, of the structure and role of the Public Health Service are yet to be published, and the NTA business plan, published at the start of October, can't yet reflect changes that have yet to be announced.

This lack of detail hasn't (of course) stopped charities welcoming the changes. Addaction for example endorsed the White Paper on NHS reform straightaway, and likewise endorsed proposals for time-limits on methadone prescribing. Given the profile of Michael Howards wife Sandra Howard on their board of trustees, one must suspect that Chief Exec Simon Antrobus is playing nice to the Conservative top brass.

It will be a while before more details emerge. But a key concern in all this is where services for drug users will end up. And this includes the full spectrum of drug services from education and prevention initiatives for young people and non-users through to substitute prescribing, counselling and residential treatment options. It includes harm reduction interventions like needle exchange and longer term interventions that support the journey from problematic use to recovery for dependent use.

Some aspects of service, such as Needle Exchange, will most likely fall within the remit of the Public Health Service and be delivered via local authorities. One worries that in areas with small budgets and high demand, this will result in an increase in delivery via Pharmacy Needle Exchange as the lowest-cost option. Needle exchange has been over-stretched, underfunded and lacked a coherent set of quality standards. It will be incumbent on the new Public Health Service, in conjunction with bodies such as the National Needle Exchange Forum, to develop minimum standards for Needle Exchange in England and Wales in much the same way that Scottish Needle Exchanges are being reshaped thanks to the Guidelines on Injecting Equipment Provision in Scotland.

It's less clear where non-treatment initiatives, especially education and prevention, will come from. Where will Frank end up for example? Will he be run straight from the Departments of Health and the Home office (as is currently the case) or will he find a new home at the Public Health Service. That is of course if he survives at all. Frank could be culled as well - it would be a suprise if he survived unchanged and unscathed.

But the most vexed question is to where drug treatment services will be located. Will they be something that is commissioned and contracted by GP consortia? Or will they be one of the few aspects of patient care deemed not suitable for this model and an alternative will be developed. Almost certainly, Cameron's Big Society will be expected to play a role. This will certainly be of huge benefit in terms of involving peer support groups, mentoring and mutual aid. But it is of less use when it comes to the vexed issues of prescribing and residential treatment. Prescribing, time limited or otherwise, demands the involvement of Doctors in some capacity and so can't be done by a willing army of volunteers. Not that, on the whole, this army of volunteers would have much to do with prescribing, especially methadone.

We don't know at this stage if the funds for treating drug users (or "Problem Drug Users") and distributed as the "Pooled Treatment Budget" will be retained or not. Let us assume for a moment that such a budget is, for now, retained though possibly subjected to the same cuts being made elsewhere in the budget.

While the budget may be retained, it won't continue to be distributed or spent via PCTs as is currently the case. So where would it go? Would it go directly to GP consortia? This would be as close as one can envisage to actually putting control of the budget in the hands of the actual patient. But as some of this would need to be spent on prescribing (something currently done by GPs) there is something of a conflict of interest here - giving the GP Consortia a budget for drug treatment and then expecting them not to spend a large chunk of it on continuing to dispense methadone.

Or would the money end up being controlled by the new Directors of Public Health. And would the budget for treatment for drugs then end up as a ring-fenced fund within the wider Public Health Service budget. Were this not the case, drugs money would end up being spent on other aspects of Public Health - including prevention, smoking cessation and obesity.

Wherever the money ends up, and whoever controls it, part of the expectation at least on the Government's part, is that payment will be made by results. But this creates something of a dilemma. If as seems likely the money which was previously in the Pooled Treatment Budget is transferred across to the control of the Public Health Service, it would then end up being distributed to local authorities according to need based on the scale of the drug problem in that area. It would then need to be used to pay for drug treatment services of whatever persuasion as is the case now. The only big difference is that in theory the treatment provider would be paid by results - which using the current yardstick being brandished by the Government, would be abstinence and getting a job.

This then seems a far cry from a personal health budget which patients can use to purchase whatever treatment they want, where they want, provided it is evidence based. It will be easy for the motivated, for the "ready to quit" to access treatment - they will be manna for the "payment by result" services. Indeed the development of screening tools and profiling (or segmenting as it's now being called) will make all the difference to the profitability of these services. But for the most vulnerable, those with the most complex needs, the most entrenched habits, the risk is that they are more likely to be written off than before. Because the services that are paid by results don't want people on their books that make them look less than successful. And prescribers won't want to be drawn in to a constant battle to justify (or not, as the case may be) long term prescribing even where it may have been beneficial.

How it would be spent - and how this will be directed - may come from within the Public Health Service. But its ideological basis - that may come from another source. Some will hopefully come from evidence-based research, rather than whatever whimsical notion is currently flavour of the month on a discussion forum. But it may end up coming from just such a quarter, given shape and form by a "Addiction Recovery Board." Such a body was proposed by the Tory "Centre for Social Justice" think-tank, the brain-child of Ian Duncan Smith. So while coordination in the short term will be taken within the new Public Health Service it may well be that within this an Addiction Recovery Board will be formed to supervise and direct how money is spent and shape policy. The ideology of this post will be critical - a rigorous abstentionist in this position would have a huge impact on treatment models.

The next few months will be an interesting time. An awful lot of services are petrified that they will be decomissioned and will be jockying for position to ensure that they don't lose favour at the LibCon court. The vocal neo-abstentionists already have a ready ear in the Conservative party. They are likely to receive only muted complaints from a field that looks set to be swept away.

But these plaudits from the neo-abstentionists and quiescence from the mainstream drugs field should not be taken as a sign that all is well. There is no clear structure and the ideology is still being fought-over. It's early days and the feathers in the wind do not bode well.

06 August 2010

be careful what you wish for...

The new NTA business plan was published today and one can see the tensions between the old and new guard being played out between the lines of the document. Though in truth this document is going to be less significant than the changes that it heralds - and the structures in which they will be implemented.

There are three things that leap out at a quick initial reading:
- the priority given to abstinence is very obvious: the word is used twenty times, and most strikingly in the line "New clinical protocols will focus practitioners and clients on abstinence as the desired outcome of treatment." But desired by whom? And what of those people who wish to stop using the drug on which they are dependent, but not other substances? "Harm reduction," by comparison warrants only three mentions, one in the budget, one in relation to young people and a generic mention. "Reducing harm" has gone.

- Payment by results: the Business Plan says "We will continue to drive unit costs down by a combination of matching resource allocation to performance, progressive implementation of
payment by results..."

This throws up two substantial challenges. The first - what is the "result." Given the priority given to "abstinence" one must suspect that payment by result will be tied to abstinence as an outcome.

The second is that payment by results can result in very long timescales for payment. They tend to work in the favour of large corporate bodies who can afford the up-front costs of treatment and can await later payments. They don't work so well for small third sector organisations with limited cash flow and small reserves.

Time-limits on substitute prescribing: The business plan stresses that open-ended prescribing will not be an option most of the time and the presumption is against it. The Plan says "substitute prescribing is planned to be a time limited intervention." What the stated time limits will be are not yet clear and guidance has still to be issued.

There is at least grudging acknowledgement that some people will warrant and benefit from long-term prescribing. The Plan says "Those who need substitute prescribing beyond an initial time limit should, in turn, be reassured that it is only on the basis of a rigorous, multidisciplinary review of their ongoing needs." Reassurance really depends on your perspective. For those who argue that it is too easy for people to be left on methadone without other interventions, this review and reassessment is welcome. But for others, "reassurance" will mean a three-monthly battle to justify ongoing prescribing because they are not yet ready to reduce or stop - irrespective of the other interventions being offered to them.

In a lot of respects the Business Plan will get cautious approval from a lot of people who will see what they want in it: mutual aid groups get a mention and will be more involved; abstinence is reprioritised; there's mention of residential rehab than before though probably not as much as this Sector would have liked. But there'll also be bouquets for the mentions of time-limiting substitute prescribing and some will even cheer for payment by results.

But at the heart of this a couple of unresolved issues still remain, potent and toxic. The first is the remaining tension as to what "recovery" really means. And the Plan doesn't resolve this. On the one hand it says that "treatment gives individuals the opportunity to overcome their dependency and achieve abstinence" suggesting that it's all about abstinence.

The other says "The purpose of treatment is to enable individuals to overcome addiction. This is fully achieved when someone has completed treatment and been rehabilitated back into their community as an economically active contributing citizen." And given that we are entering terrain which will include payment by results, the definitions are all important.

Ultimately it won't be the NTA who ends up resolving these questions: but some of the voices that will be shouting loudest will be the ones who tie it to abstinence for ideological, not evidentiary reasons.