NSPs in a Recovery Orientated System
The UK is moving inexorably towards recovery-orientated treatment for drug and alcohol problems. In February 2010, the National Treatment Agency affirmed its commitment to developing recovery-orientated treatment systems in England, and recently published a twenty-page “Commissioning for Recovery” guide for service commissioners and joint commissioning groups, exemplifying the NTA’s re-visioning of the 2008 drugs strategy within the conceptual idiom of recovery. This is a welcome response to the diverse grass-roots, academic, and political critiques of the UK’s provision.
There can be no question that recovery is now a fixture of mainstream discourse and is set to become a defining and instrumental feature of the policy and treatment landscape in the UK.
Whilst there is absolutely no suggestion that Needle & Syringe Programmes (NSPs) and other harm reduction initiatives will disappear under recovery-orientated modalities, this article argues that although NSPs are rarely discussed in contextual relationship with recovery, their low-threshold, open-access structure position them as fundamental and critical elements of a recovery orientated treatment system.
“Recovery” has multiple associations and manifold influences. UK readings of US experience tend to identify “recovery” as synonymous with abstinence and 12-step mutual aid. The embryonic UK recovery movement, although significantly influenced by this account of US experience, is in the process of negotiating the boundaries of its own conceptualisation of “recovery”.
Definitions of recovery are notoriously (and perhaps unavoidably) tendentious. The following formulation utilised by the Department of Behavioural Health, Philadelphia, US, is a usefully inclusive reference point:
What is emerging in the UK is a robust and extensive end-to-end vision of recovery that seeks to consolidate the superabundance of statutory and 3rd sector treatment services with a wider network of reintegration and community provision and independent grass-roots recovery movements.
NSPs and harm reduction
It is impossible to discuss NSPs without considering the ideological driver for their inception and development into a distinct field of professional practice– the harm reduction paradigm. NSPs were the beating-heart of early harm reduction initiatives, which, in a radical discontinuity with past treatment modalities, focused on the attraction and retention of injecting drug users and providing services that promoted safer injecting practices with a view to reducing the risk of HIV/ AIDS (and latterly other viral and bacterial infections) which were seen as a greater harm than drug use itself. Drug dependency was not challenged and abstinence, although a key influence for individuals entering treatment and the gold-standard of harm reduction goals, slowly slipped beyond the horizon of expectations
Catalysed by the HIV/ AIDS crisis of the 80’s, a robust public health approach developed that privileged the minimisation of the multiple harms associated with injecting drug use. Recovery and harm reduction are often polarised as oppositional ideological paradigms. This is neither useful nor accurate. For the purposes of this discussion, I suggest that recovery is best understood as an organisational attitude that seeks to maximise the positive outcomes of harm reduction.
One of the key principles of a recovery-orientated model is it’s integrated. That is, all of the constituent parts, all the various elements of a local system are co-coordinated, speak the same language, communicate with each other and have a congruous set of values and principles that orbit around the affirmative and empowering possibilities of recovery. Every part of the system is involved in a collaborative effort to increase positive outcomes and take a long-term view with respect to developing the quality of life for individuals who access their services and disrupting negative therapeutic expectations where they occur.
This contrasts markedly with the tiered system of the NTA’s “Models of Care”, which, coupled with a dynamic if bellicose competitive commissioning/ tendering cycle has engendered a fragmented treatment system with individual tiers and their respective providers separated from one another both materially and ideologically. Each tier, sector, and service is compelled to privilege its own interests above the needs of service users, who may not necessarily benefit from being locked into a single service or artificially created strata of provision.
Recovery-orientated treatment systems (which we can expect to replace “Models of Care”) re-situate the individual at the heart of provision and encourage vibrant inter-service partnerships. A local recovery-orientated treatment system allows greater flexibility and non-linear movement between system elements. Thus, it should be possible (where appropriate) for a user to move from NSP engagement to in-patient or community detox, residential or community rehab, supported access to mutual aid groups, and direct referral to reintegration services such as housing, education, employment, training, and welfare.”
Building on strengths developed over 25 years, recovery focused NSPs will ensure responsive, needs-based placement to the most appropriate service from locally available choices. This will depend on apposite and effective assessment, the responsiveness of the local system, and the vision, drive, and leadership of NSP staff.
Low-threshold, high expectations
From the perspective of integration, the principle value of NSP’s in a recovery orientated model is that they offer open-access, low-threshold point of entry into the system for populations with the greatest needs – those with high problem severity and low recovery resources. In a significant number of cases, NSPs are often the only touch-point that members of this drug-using population have with local drug-treatment services.
Although NSP outcomes tend to be framed in a negative discourse of risk minimisation, the real-world benefits of NSPs are overwhelmingly positive. As a corollary of promoting harm reduction goals of safer using, stabilisation, and use-reduction, and without locking service users into restrictive and obstructive disciplinary treatment regimes, NSP engagement:
- Contributes to a better quality of life.
- Removes barriers to health care access.
- Promotes self-control and self-efficacy.
- Encourage autonomy and personal responsibility.
- Provides opportunities to increase knowledge and self-awareness.
Thus, NSP’s are directly linked to key recovery-orientated goals in terms of facilitating the accumulation of vital recovery resources, particularly within the domain of personal recovery capital. Recovery success can be directly linked to increases in recovery capital – that is, resources in the personal, social, and communal domains of an individual’s life that can be drawn on to support and sustain long-term recovery. Small incremental gains in the area of physical and mental health, wellbeing, and self-efficacy at this stage are significant as they can act as catalysts and triggers for long-term accrual of capital in other recovery domains.
Self-change: the heart of recovery
Gaining control over one’s injecting practices demonstrates that injecting drug users can be effective agents of self-change. Self-change is the heart of recovery: the notion that an individual can radically transform their relationship with their own selves, others, and the world. From this perspective, NSPs should be considered, and positioned as, recovery outposts; and NSP workers as vanguards on a terrain of recovery choices. Highlighting and celebrating the reality of supported self-change is vital in a recovery-orientated treatment system in order to raise aspirations and create opportunities to further self-change and personal development.
The therapeutic milieu
A recovery focused NSP will be driven by a vision that creates a therapeutic space conducive not only to safer injecting practices, but also to actively promoting and supporting engagement for long-term recovery from problematic substance use. Ideally, this means making visible recovery successes and articulating a robust, realistic narrative of recovery that is meaningful and appropriate to the injecting population. This is not something that can be determined centrally, but requires local dialogue and consultation amongst service users, providers, and recovery mentors.
The therapeutic milieu of a recovery focused NSP would evolve locally and be determined by the quality of:
- The local service ecology and its commitment to recovery-orientated provision.
- NSP/ pharmacy teams and their leadership.
- Local mutual-aid and grass-roots recovery communities.
- Wider community attitudes and partnerships.
- Local recovery champions and recovery mentors.
- The local spirit and ethos of recovery innovation and collaboration.
Making recovery success visible
Those with the most chronic problems often exist in a world of perceived hopelessness and negative self-expectations. Taking advantage of their access to difficult to engage populations, recovery focused NSPs will pro-actively make visible recovery success – for example, through employing workers or volunteers in recovery (the therapeutic power of a positive encounter between a drug user and an ex-drug user should not be underestimated), promoting local recovery champions and mentors, encouraging reciprocal working relationships with other recovery and reintegration services, and providing access to recovery information and resources that demonstrate the reality of long-term recovery from addiction.
The bottom line of recovery can be expressed in three words: recovery is possible. If recovery is possible; that is, if there is an authentic, realistic possibility of recovery then there is arguably an ethical imperative to promote and provide access to services that deliver recovery orientated change. Whilst NSPs have a very specific remit that focuses on the reduction of harm associated with drug use, their services can be delivered in a recovery-aware environment that is engaged with the full range of local recovery and reintegration provision, and firmly, authentically rooted in community. The journey towards a full and meaningful life that is recovery can begin in the most unlikely of places. Why not through the doors of a needle exchange program?