1. Addiction Treatment Outcomes Prof Michael Gossop National Addiction Centre Maudsley Hospital/Institute of Psychiatry

2. Why should we be interested in outcomes?

3. Natural history

5. Why should we be interested in outcomes? Treatment effectiveness

6. The Clinical Fallacy

7. Heavy drinking TreatmentOutcome A common but mistaken model of treatment outcomes

8. Heavy drinking TreatmentOutcome (Pre-treatment problems affect outcomes)

9. Heavy drinking TreatmentOutcome Therapists respond to presenting problems by providing targeted interventions

10. Heavy drinking TreatmentOutcome [ - ] [ + ] Presenting problems lead to altered treatment interventions as well as affecting post-treatment outcomes.

11. Heavy drinking TreatmentOutcome [ - ] [ + ] Presenting problems lead to altered treatment interventions as well as affecting post-treatment outcomes. Psych. factors Content & Process Environment

12. Multidimensionality (multiple outcomes) Drug outcomes Route of drug administration Alcohol outcomes Social adjustment (e.g. employment) Crime Mental health Physical health Mortality

13. PROBLEMS DEPENDENCE Problems and Dependence: two separate dimensions

14. NTORS The National Treatment Outcome Research Study Prospective cohort study. 1075 clients admitted to treatment. Treatments representative of 4 national treatment modalities. Repeated follow-up over 5 years.

15. Regular heroin use (NTORS methadone programmes) from Gossop et al., 2003)

16. Regular heroin use (Methadone treatment : TOPS/US)

17. Related Outcomes

18. Regular heroin use (NTORS methadone programmes) from Gossop et al., 2003)

19. Regular non-prescribed methadone use

20. Regular benzodiazepine use

21. Injecting and sharing – methadone programmes

22. Causes of death among opiate addicts (Norway) Overdose Somatic Trauma

23. Mortality Rates Prior to, during, and after maintenance treatment (Norway)

24. Anxiety and Depression (5 year outcomes: methadone programmes)

25. Time to follow-up Is bigger better?

26. Psychiatric symptom scores (Short-term outcomes: methadone programmes)

27. Predictors of psychiatric symptoms at 6 months Pre-treatment symptom scores Heroin use at 6 months Illicit methadone use Benzodiazepine use Stimulant use

28. Unrelated Outcomes

29. Crack cocaine Users and non-users at intake

30. Frequency of drinking: methadone programmes

31. Drinking quantity/day: methadone programmes

32. Years since 1st injection and positive hepatitis serostatus (Noble et al.,2000) HCV HBV

33. Returning to …... Related Outcomes

34. Crime What is it? Where does it come from?

35. Since it came to power in 1997, the New Labour Government created more than three and a half thousand new ways of becoming a criminal.

36. “The more laws, the less justice” German proverb

37. “The more laws, the more offenders” Thomas Fuller, MD, 1732

38. Selling a grey squirrel. Importing Polish potatoes. Offering to sell a game bird killed on a Sunday. Allowing an unlicensed concert in a church hall. To enter the hull of the Titanic.

39. To cause a nuclear explosion.

42. Types of acquisitive crime before admission to treatment (percent of NTORS cohort) (from Stewart et al., 2000)

43. Total crimes reported before admission to treatment (NTORS) (from Stewart et al., 2000)

44. Involvement in acquisitive crime during 90 days before admission to treatment (NTORS) (from Stewart et al., 2000)

45. The majority of the acquisitive crimes were committed by a small minority of the NTORS clients Over three quarters (76%) of the total number of acquisitive crimes were committed by just 10% of the sample.

46. Acquisitive crime: methadone programmes

47. The association between drug use and acquisitive crime Heroin: Odds = 11.4 (4.1-32.0, 95% CI) Cocaine Odds = 3.1 (1.9-5.0, 95% CI)

48. Acquisitive crime: methadone programmes

49. Regular heroin use (NTORS methadone programmes) from Gossop et al., 2003)

50. Acquisitive crime: methadone programmes

51. Measures of Crime Offending Behaviour Arrests Convictions

52. Criminal convictions (all): NTORS clients

53. Criminal convictions (all) NTORS clients: Methadone and Residential

54. Acquisitive crime convictions: NTORS clients

55. Drug selling convictions: NTORS clients

56. Exceptions to the general pattern of reductions in crime Robbery and serious crime Women

57. Violent crime convictions: NTORS clients

58. Addiction disorders within the criminal justice system

59. Drug use by prisoners in year before custody (from Stewart et al., 2008)

60. Management of opiate withdrawal syndrome after arrest

61. Persistence of drug use during imprisonment

62. Risk of overdose after release of detoxified opiate dependent offenders from prison