Malcolm Carr is Director of Clinical Services at the Harrogate Clinic (part of the Cygnet Healthcare Group), which provides the Detox 5 treatment programme. We spoke to him about the different aspects of addiction treatment and services.

What does your role involve?
'I'm director of clinical services at the Harrogate Clinic. That encompasses an acute psychiatric service, which is a 19-bed psychiatric ward, and Detox 5. I'm also the registered manager under the auspices of the healthcare commission.'

In the 30 years that you've worked in psychiatric services, have you seen much change in patterns of heroin usage?
'Phenomenal change. In the 1980s, inpatient addictions work seemed to be much more focused on alcohol problems. There was also quite a lot of work directed towards amphetamine use. Specialist drug services were few and far apart. A report by the ACMD (Advisory Council on the Misuse of Drugs) in the early 1980s led to the creation of CDTs (Community Drug Teams) to increase access to treatment. We did see some people on opiates, but the real explosion appeared to come in the late 1980s to early 1990s. Statistics show that opiate usage has increased – the usage of illicit drugs per se has increased. We're increasingly seeing people who are identified as poly-drug users, meaning they use more than one type of drug.'

In your opinion, is residential rehab the most effective way of dealing with addiction, especially for opiate users?
'No. Although I manage what's called a Tier 4 Service, which is an in-patient detoxification service, for many people treatment and care for their opiate use can be managed in the community. Until 2000–2001, we were still very much focused on abstinence as an end point, but in about 2001 we started to look much more at harm reduction, and since then we've seen a significant number of people coming into treatment and people being maintained on methadone. As well as methadone, there are other treatment options, such as lofexidine and buprenorphine (Subutex). What has caused concern to some people has been the lack of exit points from treatment. Harm reduction enables service users to move from 'chaotic' drug use into stable treatment. What has been lacking for many was a further step towards abstinence.'

What about naltrexone, which is used in Detox 5? Is this widely used?
'We've been using it since 1996 when we started the Detox 5 project. There's certainly been a big increase in the use of naltrexone in the last four or five years. The Royal College of General Practicioners have a training programme, GPWSI, for GPs with a special interest, and this means that GPs involved in care in the community have developed an increased awareness of treatment options, including naltrexone.'

Although you work in the independent sector, can you comment on addiction services available on the NHS at the moment?
'Since the advent of the National Treatment Agency there's been a real increase in treatment availability. The number of drug workers has increased exponentially – there really are lots of drug workers out there. One issue is that drug workers have been recruited so quickly that keeping training programmes up to date is difficult, but lots of work is being done there.'

Do you feel that drug users are getting younger or that young people are more vulnerable to drug use than they have been in the past?
'I think younger people are getting involved in drug use - not just opiates, all drug use. But it's one of those catch-22 situations in that we've got to educate people, but one of the conundrums is that when you tell young people something's bad for them, they want to try it. Education is important. The issue is how it's delivered: it's about getting the right message across in a way that young people want to pay attention to.'

Naltrexone
This is an opioid receptor antagonist, which means that it blocks or weakens the effects of opioids such as heroin. If someone uses heroin while taking naltrexone, the heroin will not have any effect. However, taking naltrexone on top of heroin use will make you feel very ill and should not be done.

National Treatment Agency
The National Treatment Agency (NTA) is a special health authority, created by the Government in 2001 to improve the availability, capacity and effectiveness of treatment for drug misuse in England. www.nta.nhs.uk