Retention in treatment has been traditionally regarded as a key outcome measure of addiction treatment. Thinking about this indicator brings us to fundamental questions of what a success in treatment is and how it can be measured.
The longer drug users stay in treatment, the higher their chances of success. Their health improves; they commit less crime and have more stable daily routine. Early identification and treatment of drug problems is also associated with better outcomes. NIATx, for instance, is an easy to use model of process improvement designed specifically for behavioral health. It helps substance abuse and mental health treatment organizations improve user access to and retention in treatment, defined as “attendance at the second, third, or fourth outpatient treatment sessions”. Others regard 12-month retention in care as success.
Rowdy Yates said, at the INEF conference in Dublin, 2011 that drug users seeking treatment want to give up drugs and what they get from us? Methadone [a replacement opioid]. This statement reflects the inability of many treatment systems to offer a menu of options and tailor them to individual needs of drug users. Medicating drug problem is one of the solutions that work for a large population of treatment seekers. Other options should be offered too.
Dr Okruhlica, in Slovakia, agrees with the diagnosis of addiction by the International Classification of Disorders (ICD) or Diagnostic and Statistical Manual DSM. This definition lists several symptoms of addiction. If somebody has certain number of these symptoms, they receive the diagnosis. If the person doesn’t have symptoms for a year, they cannot be regarded as ill any longer. Harm reduction experts believe that while the medical diagnosis of addiction could be helpful in understanding the problem, even the most dependent users have control over their drug use and choice plays an important role in their life. Dr Zinberg was a pioneer of this approach with his monograph The Basis for Controlled Intoxicant Use. Studies on uncontrolled drug use followed. These views are regarded as extreme by many. Their believability is further undermined by the fact that non-problem drug users live in anonymity. For example, very few scientific studies manage to engage with non-problematic heroin users.
On the other hand, the recovery-oriented movements, especially AA, maintain that once a person “gets” addiction, they will become ill forever. This opinion can be very helpful for people in treatment, but can actually harm people out of treatment. Ex-users seeking re-integration into job markets are viewed as irresponsible and incapable of holding jobs for long time – result of a society stigmatization.
Because retention in treatment, as a robust outcome indicator, is highly esteemed in the drug addiction field, most professionals working in the addiction are able to place them somewhere on the continuum delineated by the two extremes – illness for life vs. uncontrolled drug use. See figure 1 below.
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| Figure 1 Continuum of opinions |
Alongside the controversy around medicalization of drug use runs another debate about language. For many, language doesn’t matter too much and is a matter of political correctness. Opposite to them, I would like to hope, stand the language-believers. For them, the words we use shape and influence the world we live in. If we call drug users “junkies” they will become “junkies” – whatever that word represents to those who use it. Similarly, the term retention could be too close to detention; people are not kept in treatment to help them regain life, but to help sustain the treatment centre. Just like in the prison, where the inmates have little control over their length of stay, the people detained or retained in treatment have little control over length of their treatment. Opponents of the word retention propose continuity of care as an alternative, more humane, term to describe this golden-standard treatment outcome indicator. For them, it incorporates also the individual willingness to receivecare. But, are patients aware of it? I ask.
Language shapes and influences the drug treatment systems that we study or work for. It is important to recognize that even though retention and continuity of care could be the same thing – looked at from different angles – we have to choose the words we use in treatment carefully and make sure people who use our services are aware of it.