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Keywords:

  • Drug treatment;
  • treatment accessibility;
  • treatment availability;
  • treatment quality;
  • service system;
  • unmet treatment demand

If the central goal of Humphreys & McLellan's paper [1] is to answer the question ‘how can policies improve treatment outcomes’, then I would argue that the most important policy would be an increase in the quantity and accessibility of treatment. Across the globe, there is not enough alcohol and drug treatment and the existing treatment is too inaccessible [2]. If one metric is unmet need, as measured by the numbers of people at a population level who meet criteria for dependence or harmful use, who would benefit from treatment but do not access it, then the figures are astounding [3]. However, need for treatment is not the same as potential demand for treatment. Unmet demand for treatment is the number of people who want to access treatment but cannot or do not access it for any number of reasons: the treatment services do not exist; they have no vacancies; the treatment is too expensive for the patient to afford; treatment is not physically accessible (i.e. too distant); and/or treatment does not cater for the patient's needs (e.g. childcare arrangements). There are substantially more people who require treatment than receive it, pointing to a fundamental problem with amount of treatment, over and above any quality issues. Various estimates indicate that the highest treatment penetration rate may be in the order of 50%, and only for heroin-dependent people seeking pharmacotherapy maintenance [4].

Studies of treatment expansion, such as that by Emmanuelli & Desenclos [5] or Nordt et al. [6] demonstrate that expanding treatment services produces the expected clinical outcomes; but, as argued by Reuter & Pollack [7], treatment provision does not eliminate the drug problem. This argument would also apply to Humphreys & McLellan's analysis—drug treatment is not a panacea for population reductions in dependence or harmful use, irrespective of whether the focus is on quality improvement or expansion of the system itself. None the less, a considered decision is required as to whether policy makers should focus on funding more treatment places or focus on improving the quality of existing services. Humphreys & McLellan's paper focuses on the latter. I would argue that the former may be a better investment. This is an empirical question; is quantity of treatment a better policy choice than improving the quality of the existing limited services?

A second issue raised by the Humphreys & McLellan paper concerns whether the quality of drug treatment is more important than provision of the associated welfare and social services. Social and welfare support services may be more pivotal than ‘active’ treatment. Those of us who have worked in the field know the difference that stable accommodation, meaningful daily activities and friendship circles can make to someone's recovery from dependence on alcohol or other drugs. Sessions of cognitive–behavioural relapse prevention pale into insignificance when compared with the power of these practical interventions and supports. Governments that focus on improving housing support, employment support, reduction of poverty, provision of meaningful daily activities and support for community engagement may find that drug treatment outcomes are substantially improved in those circumstances. Again, this is an empirical question; does investment in social and welfare support deliver better outcomes than improvements in quality of existing services?

The above points beg the question about the kinds of research we are undertaking. Both questions—quantity versus quality and quality versus welfare and support services—are not the subject of current research, as far as I can ascertain, nor are there seminal studies answering these questions. Much treatment research is focused on improving the efficacy of existing interventions—certainly worthwhile. However, there is a lacuna when it comes to studying treatment systems, population needs assessment, population treatment outcomes and treatment structures, such as is suggested by the above two points. If we take Humphreys & McLellan's call seriously—to inform policymakers about the best options—we need to revise our research efforts to focus on those questions which will make a difference to decision-making.

Declarations of interest

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  2. Declarations of interest
  3. References

Alison Ritter is funded through an NHMRC Career Development Award.

References

  1. Top of page
  2. Declarations of interest
  3. References