Episode 2: Combatting The UK Heroin Epidemic
This episode takes us to the UK where Mike Trace recounts C4’s involvement in setting up a national recovery program under Tony Blair’s government. Mike is joined by Dr Bob Lynn for a panel discussion on the creation of the UK program.
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Jack O’Donnell Welcome to the second episode of C4 Recovery Solutions podcast. I’m your host, Jack O’Donnell. Some of you might know me as the CEO of C4 Recovery Foundation. As many of you know, C4 is dedicated to improving access to high-quality, ethical treatment services for behavioral health and social wellness. We are fierce advocates for the often overlooked individuals and underserved populations within our society. Through innovation and forward-thinking, C4 has developed service delivery systems for addiction and recovery programmes throughout the United States and throughout the world in some of the most challenging environments.
Each week on this podcast, we will hear stories from people who have benefited directly from programmes C4 developed, those who assisted C4 in the process, and especially those still involved in the implementation of the programmes today.
On today’s episode, we are discussing the issue of decentralised structures of treatment services. Public sector treatment programmes have three main steps: service commissioning, service purchasing, and service delivery. When these steps are each controlled by disparate bodies, it muddles the system, making it harder for people to get help.
This was a situation in the United Kingdom in the late 1990s, before C4 stepped into design and implement a centralised coordinating body, the National Treatment Agency or NTA, from 1999 to 2002, The main issue was whether such a big new investment would be spent efficiently. This is where Mike Trace comes in. Based in London, Mike experienced the disorganised system before C4’s intervention and the drastic transformation that followed. And now here is his story.
Mike Trace What we wanted to do in the national policy is – is make sure there were good services in every area of the country. In the early parts of my career, I worked with the homeless and people in prisons in London as a social worker and street outreach worker. I also worked in the USA for a year, in California with the Youth Authority there. So, I learnt about drug problems, drug addiction on the street, so to speak, on the front line. And also because of my age, I was at the coalface when a real, large-scale heroin addiction first hit, you know, upon the USA.
Treatment provision in the UK has always been localised. But before the late 1990s, this was very patchy service provision. If services are fragmented and not very well-planned, that absolutely undermines the effectiveness of the system. So, we had a lot of services doing the best job they could. But they weren’t partnered with other services. There was no continuity of care. There was no planning. So, they would work well within their own jurisdictions. But there was no coordination and careful strategy. So, that undermined their effectiveness.
Before we brought in this national policy, some areas of the country had no money at all. Some areas of the country put all of their money into methadone prescribing. Some other areas of the country had twelve-step programmes, but nothing else. It was entirely accidental what parts of the country had a treatment offer.
The biggest problem in the eighties and nineties in the UK was that the – the mismatch between the demand for treatment on the availability. When the heroin problems developed in the UK through the eighties and nineties, they were concentrated in the big cities. So, there were large numbers of people that took the services by surprise. They suddenly needed help. And there wasn’t much help there for them. So, it’s very hard for individuals to identify and decide that they wanted to go into treatment. It would be very hard for them to find out where the help could be received and also to get quick access to it. So, you know, it would very much depend on whether they were lucky enough that there was a local service that was accessible. Some people were lucky, but most people were not.
Rather accidentally, it was Tony Blair, when he became prime minister, who recognised something needed to be done about the level of drug treatment in the country. He didn’t really have a sophisticated analysis of what should be done, but he did make the political decision that saw treatment needed to be part of our response together with policing and punishment and prisons. Very much in favor of treatment and instead of punishment for people with drug and alcohol problems. So, when Tony Blair’s government came into power in 1997, he came in with a big social agenda. And part of the agenda was to expand our treatment system.
I was appointed as the deputy drugs are within six months of that government coming into power. And within the first couple of years of our strategy to improve treatment services in the UK, we had a big investment of cash. In the UK, we have a national health service. So, social care and health care is nationalised and it’s funded by the government. And those investments were increased five hundred percent in the three years following 1997. I’m the lucky person who was in the right place at the right time who had to design the way we spent that money. We wanted to spend the money as efficiently as possible. And we wanted every town, every city in the country to have a menu of services that works in a coordinated way. We inherited a – a mess of services, but some very good quality services. But they were not a system. So, one of the main priorities for me when I was in control was to have a systemic approach to delivering all aspects of care in a very coordinated way in every area of the country.
When I look back on what we tried to do in the UK twenty years ago, we have much more treatment availability now than we did twenty years ago. That’s good. But when I look at the UK system and I look at the US treatment systems, we still have a major problem. We’re – we’re spending an awful lot of money that has the objective of giving good treatment and recovery to as many people as possible. But that money is not being spent efficiently. Good political commitment, a lot of money spent, but it’s spent in a very complicated, piecemeal way and it really does need both countries leadership again to take an overall strategy and say, “Are we getting exactly what we want out of this investment?”
And I see that Biden’s making some very good statements about what he wants to do around drug treatment. That’s great. But it’s the money. Where the money goes, who spends it, and what they spend it on is really crucial. And I think the US and the UK need a national drive now, in 2021, to get that money spent a lot more sensibly. That this is not a sorted problem. It’s still a task.
Jack O’Donnell As Mike touched on, when public sector treatment programmes are completely fragmented, it makes it harder for the people who need help most to receive it. When C4 was asked to help set up the Liverpool pilot in 1999, it revolutionised the addiction treatment system in the UK by giving the thousands of independent structures providing localised care one single, centralised coordinating body. Providing a central authority made it possible for the first time to collect treatment outcomes and to help write relevant national policy.
NTA, or the National Treatment Agency, made it possible to commission services equitably across the country, because, at long last, there were standards of treatment services. With central budgeting oversight and care coordination, there was finally guidance on moving folks through different levels of care.
For today’s panel, we are joined by Mike Trace, the deputy drug czar at the time the NTA was founded, and internationally-recognised lecturer, researcher, and clinician in the field of counseling psychology and addiction. Dr. Bob Lynn.
Bob Lynn Well, it’s an interesting story. We began a pilot programme, if you will, in New Jersey. Mike heard about the programme from Rick Ohrstrom, becoming curious and interested in what we were doing. And we were having some compelling results. Mike put together a coalition of folks from the UK to come and visit us in New Jersey. It was retrospectively one of the most momentous visits of – of – of – that I can remember. It was really the sharing of – of information. It was really a place that we were breaking down some silos and barriers and beginning to learn from each other. And as a result of that meeting, we were invited by Mike to come back to the UK and begin to develop similar programmes in England.
Jack O’Donnell So, Mike, you’re in the UK. When did you realise that there was a serious problem with the delivery systems for addiction?
Mike Trace I came into UK government in ’97, and we started spending serious money on expanding our treatment system through ‘99, 2000. We knew, in the UK system, you raise taxes at central government and then you pass them down to local administrations to spend. So, we were passing hundreds of billions of pounds down to local areas, and we didn’t trust them to spend it wisely. It’s always a problem in the UK system, is that money can disappear and be spent very inefficiently if you’re not careful. So, in this sector, substance misuse treatment, we wanted to be sure that the money would be spent in a balanced way to expand treatment availability, but also it would be spent to build a system, not a series of fragmented services that didn’t talk to each other.
And I thought, after speaking to Rick and Bob and others at C4, I thought the biggest way to ensure efficiency in our system was to have some sort of case management and client advocacy system. And that’s where we started the thinking about ETO and everything that followed it.
Jack O’Donnell So, you’ve got this problem, but yet you have to prove to the government that you can execute a system that’s going to work before they spend all this money. What was going on in Liverpool that that became the target for the pilot programme?
Mike Trace Probably somewhere around 2000, 2001, we put out a call for local areas to be pilot projects of this new approach, more coherent approach. We got a whole number of applications. I think we chose five or six areas to be part of the pilot. And right from the start, Liverpool was always the best organised, most enthusiastic about this potential. That particular project came and went pretty quickly. But the relationships and the proposals that were put together in Liverpool outlasted the pilot. And the model that me and C4 wanted to see implemented got implemented most purely in Liverpool.
Jack O’Donnell So, C4 is now asked to participate in developing this programme and being involved in the pilot in Liverpool. So, Bob, you’re sent over to – to London. What was your assessment of the situation when you got there?
Bob Lynn There were five or six different participants in the initial study. And we had various levels of success in each one of these – these different geographical areas. And in Liverpool, we had a lot of enthusiasm. So, that was one of the reasons we continued in Liverpool. And at the time, the consulting psychiatrist was the person, really, in charge of the area. If you… You know, if you really wanted to get anything done, you really needed to have a partnership with that group. And so, we were introduced to the consulting psychiatrist. She was enthusiastic about the whole idea of centralising treatment in a way that we were able to link twenty-plus treatment programmes, so that – that we can provide seamless care across the care continuum. We actually did not have to get any new funds. What we really did was reorganise some of the systems that were already in place.
And there were, you know, there were social workers who were going out to treatment centres on a, you know, a regular basis, but were not highly organised. What we basically did was organise them into a central intake model where clients could actually come through the initial centre and receive treatment and be referred. They’d get a full, comprehensive evaluation. And then, we’d create a partnership with one of the treatment centres and send them to the treatment centre. We also developed a relationship with the centres themselves where they enrolled their current clients in the system. So, if an individual left treatment, their – their evaluation would follow them.
And we had a really large reception where we invited police. And I mean, everything from clergy, police, employers of different sorts, medical personnel, all came together as stakeholders and became part of the system. So, it wasn’t only treatment centres, but it was really a – a community-based programme. And it – and it was – it was rather dynamic.
You know, as I mentioned, we used existing resources and funds. But we used them in such a more precise way that services were not duplicated, assessments were not duplicated. A three-week withdrawal management detox system turned into a one-week system. And we were able to move that people through the continuum more quickly.
Jack O’Donnell C4, really, has now a thirty-year history of developing really kind of community-based programmes. Back then, you know, what was the reaction to the – the local people, so to speak, of doing this outreach into areas that you traditionally wouldn’t have reached out to as just the treatment provider? What did the community think about this?
Mike Trace Well, as Bob said, in Liverpool, I think the reception was very warm. And if you get key partners involved in any particular area, then that has a lot of credibility. So, C4’s work in Liverpool had a really good push from having some key people publicly back it. And it was generally quite visible quite quickly that this was having good results. So, I think that’s an example where there wasn’t really any great pushback. From my memory, the real resistance we had was from some of the, may I say, vested interest in the treatment system that didn’t want too much scrutiny. Basically, what the case management ETO model was was casting a very strong torchlight on weather services and processes were effective. And there were some providers on some system coordinators who didn’t want that level of scrutiny. So, we did have some resistance.
Jack O’Donnell You know, how did you track your clients and how did you get to the point where you said, “Hey. This system really works. We’re helping people for the long haul?”
Bob Lynn It’s very difficult to change embedded systems. You know, we’re talking, at that point, you know, maybe twenty years of – of – of a belief system and an ethos that was so embedded that people coming in and – and asking to do things differently was apt to create some resistance. And, you know, there was no doubt about that. So, to answer your question, you know, what we did was we began to look at not just outcomes in the more classical sense. You know, historically, people would look at outcomes based on abstinence. When did you take your last drug? and, you know, What does that feel like? and Do you… Are you having cravings? and all those things.
We went way beyond that, Jack. And we started to look at what’s called proximal outcomes. In other words, we looked at family intactness. You know, are people participating in treatment? Are they – are they getting jobs? Are they meeting their individual goals? We started to look at those kinds of things as opposed to simply how long you were staying drug-free. And that created a whole new – a whole new science for us, in a sense. You know, a whole new way of – of thinking about recovery, rather than thinking about a recovery as – as a line in the sand that you pass. We began to see recovery as a journey, as a continuum. We found that, you know, quality of life began to improve. Things like stigma. You know, thoughts about stigma were being changed, because once you get the community involved and the people start hiring folks and start seeing people, you know, in recovery, you begin to change thinking. But then, you know, it takes – it takes a while to do that.
Jack O’Donnell So, Mike, from the time the game plan was launched, so to speak—and I understand that it was actually at a football match where Mike Trace and Rick Ohrstrom pulled out a napkin and started designing this programme, so to speak. From that day, how long did it take before you finally launched the – the programme itself?
Mike Trace It’s true. A lot of the ideas we had first at that game became the NTA and became the – the case management model that Bob’s described. I don’t think… It – it did happen over a couple of years. It has had a longstanding impact in the UK. Case management approaches are now normalised in the UK. I don’t think they’re working in any way as efficiently as we dreamt of. But they are bedded into our system. And the other thing I’d say is that the other part of the timing that was bad is just as this was gaining momentum in places like Liverpool, that’s when I started to move away from the job I was doing with the National Treatment Agency and move onto other things. And I don’t think the people who took over from me at the national level had the same level of support for this initiative that – that I had given. So, we lost a bit of momentum there.
I don’t know how it felt from your end, Bob. But, you know, I know you could still do the work locally. But you didn’t have as much political support if you like from the centre.
Jack O’Donnell You know, that’s a good point. I think we find that in every jurisdiction that we go. That some people, whether it’s at a national level or whatever, are a little bit slower to grasp what we’re doing. But I think—Bob, you can correct me if I’m wrong here—I think that the programme was recognised. I know, because C4, you know, continue to do a lot of work in the United Kingdom after the Liverpool pilot. Is that true, Bob?
Bob Lynn Mike left the NTA, and the NTA itself was going through some of its own internal changes. And some of that was spilling over to us. We were working, if you would, kind of beyond the NTA in a sense, because we were being contracted on the local level as opposed to the national level. And it was just through word of mouth, reputation. And we began to do work in different areas. And that work really expanded, because, you know, it wasn’t just developing these kinds of systems. It was evaluating current systems and doing some training on local levels. And – and we – we stayed in the UK for many years and we got involved with some of the folks in the universities. You know, we had… We did other kinds of trainings together. We did joint trainings with folks in the UK.
So, all of the work that we were doing, Jack—whether it was training, whether it was consulting, whether it was evaluating treatment systems—always had as its underlying belief system that we can improve care by advocating for people across the care continuum and linking disparate systems. And that – that was really – that was really a big part of it. I mean, even in a small area. I remember in one area where they only had two treatment systems. We brought those systems together at a meeting. And that was the first time that they met. And they’d worked together, you know, in this small area for years and years. And then, they didn’t even know each other. So, you know, breaking down those kinds of barriers and – and breaking down silos and developing a more seamless care continuum. People began to talk to each other. The harm reduction folks began to talk to the – the abstinence folks. And things were happening that we were advocating for. But it wasn’t only because of us. It was because of creating a system or a place that was fertile for this to happen, for it to grow. And I think people were hungry for change at that point. We just happened to be in the right place at the right time, if you would.
Jack O’Donnell So, Mike, how would you say your work has been affected by the pandemic?
Mike Trace The pandemic makes it very hard to deliver the services we normally deliver. So, outreach were, for example… You know, it’s hard to put people out on the streets to help people who are struggling out there in a lockdown situation. My organisation does a lot of work in prisons. Prisons are pretty much closed down for a year. You can’t run treatment programmes. So, all of that’s closed down. And we’re doing the best we can through phone counseling and, you know, written work. But the face-to-face work is very constrained.
At the same time, I – I see some data from the US telling the same story, is that the demand is going up. You know, if – if addiction treatment is all around, people who are struggling, lonely, you know, not being able to get access to support from family or community, there’s a lot more people in that situation than there was a year ago. So, demand’s going up. But our ability to get out and get our stuff out there and meet that demand is very constrained still.
Jack O’Donnell You know, C4 took this process that succeeded in New Jersey and we applied it successfully in the United Kingdom. We proved that our process can be adapted to operate successfully in different countries and cultures. It takes persistence and tenacity. And all parties had that in the United Kingdom.
Listen, it sounds like a real success story. This pilot, you were able to pull it off. I won’t say seamlessly, but nothing is seamlessly. Mike, certainly, on your part, I think it was visionary. I think it was bold. You had a lot of obstacles and you are to be commended for this effort that you made there. And, quite frankly, C4 is very proud to have been associated with you on this project.
I want to thank you both for your time today. I think you’ve told a wonderful story. I think you’ve let the world know that we’re out there advocating every day for people and we’re not going to stop regardless of the obstacles. So, thank you very much for telling this story.
Jack O’Donnell Thank you for listening to the C4 Recovery Solutions podcast, brought to you by C4 recovery foundation. For more information, please visit our website at c4recoveryfoundation.org or email us at firstname.lastname@example.org.
Be sure to rate, review, and subscribe on Apple Podcasts, Spotify, Stitcher, or wherever you like to listen. I’ll see you next time on the C4 Recovery Solutions podcast. Goodbye.