Geographical variations in substance misuse services waiting times and methadone treatment of opiate dependence in England andWales

RESULTS The average waiting time was 7.2 weeks for assessment and10.6 weeks from referral to receiving methadone.‘Methadone maintenance’ was not available in 25 units, although it was commonly provided in 41units. In-patient detoxification for illicit drug dependence was available in108 units, of which 59 units had access to beds in dedicated drug-dependency units, while the remaining 49 units referred in-patients to general psychiatry wards.


CLINICAL IMPLICATIONS
Despite government guidelines, it was clear that methadone was readily available to opiate users in some units whereas prescribing was very limited in others.The great variation in prescribing policies and waiting lists between community drug teams will make it extremely difficult to compare their effectiveness.Waiting lists are an explicit target for the National Treatment Agency involved in commissioning substance misuse services.
The UK NHS Plan (Department of Health, 2000) states that the public's top concern about the NHS is the time waiting for treatment.The Department of Health (1997) has also been making increasing efforts to audit and standardise care throughout the NHS by mechanisms which include the Commission for Health Improvement and the introduction of Government guidelines for the treatment of substance misuse ('The Orange Book' ;Department of Health, 1999).Efforts are also being made to determine the effectiveness of substance misuse services at a national level throughout the UK, for example the National Treatment Outcome Research Study of 1075 clients (Gossop et al, 1999).The length of waiting lists is also one of the targets selected by the new National Treatment Agency, which is responsible for commissioning substance misuse services in the NHS (Department of Health, 2000).However, there have been no recent assessments of the waiting list in England and Wales for community substance misuse treatment services or their prescribing policies.I therefore chose to survey the geographical variations in waiting times for both assessment for opiate misusers and for the prescription of methadone.Regional availability of methadone maintenance and in-patient detoxification was also surveyed.
In the 1980s, community drug teams were established in each health authority throughout England and Wales to absorb most of the demand for treatment as the prevalence of substance misuse increased.There are almost 200 community drug teams providing a multidisciplinary approach to treatments including counselling, needle exchange facilities, substitute prescribing and access to residential detoxification and rehabilitation facilities.The teams are the principal statutory prescribing services for substance misusers in the UK (Royal College of Psychiatrists, 2000).
Methadone is an opioid drug that is used to prevent withdrawal symptoms in clients with opiate dependence, including persistent intravenous heroin users.It is probably the most widely used agent for the treatment of opioid dependence in the UK (Royal College of Psychiatrists, 2000).Methadone may be used either for maintenance, which involved prolonged prescribing with no requirement for the dose to be reduced, or for detoxification, when the dose is gradually reduced over a period of days or weeks (Department of Health, 1999;Leshner, 1999).

Method and results
Between October 2000 and April 2001, a postal questionnaire was sent to the manager or charge nurse of each of the 170 community drug teams in England and Wales, listed in the Standing Conference on Drug Abuse (SCODA) directory of substance misuse treatment services (SCODA, 1988).Respondents were asked to report the waiting time for assessment and methadone treatment of clients in their service.They were also asked about the availability of methadone maintenance and inpatient treatment for detoxification and rehabilitation (excluding emergency admissions following psychiatric crises).'Methadone maintenance' was defined as 'the prolonged prescribing of methadone to the client with no requirement for the dose to be reduced'.
Results were obtained from 140 community drug teams (82% response rate) and are summarised in Table 1.The mean waiting time for assessment for any substance misuse problem was 7.2 weeks (standard error 11.1 weeks).Thirty-five (25%) of the units could assess clients within 7 days and 25 (18%) had waiting times exceeding 10 weeks.The average waiting time was 10.6 weeks (standard error 7.4 weeks) from referral to receiving methadone.Sixty-three (45%) of the units could prescribe methadone to suitable clients within 24 hours of assessment.The distributions for both waiting times were unimodal and skewed.The median and interquartile ranges for assessment were 2.5 (1.0-9.0)weeks and for methadone prescription were 5.5 (3.0-14.0)weeks.
Methadone maintenance was not available in 25 (18%) of the units.However, 41 (29%) provided methadone maintenance to one-quarter or more of their opiate-dependent clients.
In-patient detoxification for illicit drug dependence was available in 108 (77%) units.Of these, 59 (42%) had access to beds in dedicated drug dependency units, while the remaining 49 (35%) referred in-patients to general psychiatry wards.

Discussion
The Department of Health (1997) has stated that there are 'unacceptable variations in performance and practice.These variations in care are wasteful and unfair'.This has recently led to the announcement that the length of waiting lists is one of the targets selected by the new National Treatment Agency (Department of Health, 2000).At 7 weeks, the average waiting time for assessment by community drug teams was comparable with the average waiting time for an out-patient appointment for NHS mental health services (this currently stands at 6 weeks; NHS web site: http://www.nhs.uk/websites/).However, there is a significant variation between units in service provision for substance misusers.For example, 18% of community drug teams could not provide an assessment within 10 weeks, while 25% could assess within 7 days.Similarly, methadone maintenance was widely practised in 29% of services but was completely unavailable in 18%, despite considerable evidence of the effectiveness of this treatment (Farrell et al, 1994;Ward et al, 1999).Around one-third of community drug teams referred in-patients for detoxification on general psychiatry wards, although outcomes are significantly better following treatment on specialised drug dependency units (Strang et al, 1997).For drug and alcohol users seeking treatment, a recent report suggests clear and sustained improvements occur following treatment, irrespective of the length of time before treatment is given (Best et al, 2002).However, many clients regard significant regional variations in waiting time and service provision as unfair, while these variations are likely to influence the attractiveness and the effectiveness of different substance misuse services.The variation in waiting times may also have a significant impact on the commissioning of any new services by the National Treatment Agency and its assessment of existing services.original papers

Table 1 .
Summary of results of a survey of waiting time and treatments for substance misuse services in England and Wales (n=140) Factor Waiting time for assessment (weeks, s.e.) 7.2 (11.1)Waiting time for methadone treatment (weeks, s.e.)