Treatment services for those with alcohol and other drug problems change over the years, sometimes due to the whim of bureaucrats, sometimes due to political pressure, but we always hope to be informed by evidence.

Adamson et al’s paper,1 in this issue of the Journal, builds on the evidence needed to inform alcohol and other drug treatment policy, service, and workforce development. Between 1998 and 2004, the average alcohol and drug treatment-seeking client has aged and is less likely to be Caucasian, although Māori are over-represented in both years.

Māori clients are younger than other clients, more often use cannabis, and are less likely to live in a large city. Amphetamine users are younger and domiciled mainly in the North Island. In 2004, people were seen more often in community-based clinics and fewer were admitted to residential care. Those retained in follow-up treatment following an initial assessment are more likely to be female, non-Māori, and opioid users, although ‘kaupapa Māori’ services retain Māori clients better.

Since 1998, treatment-oriented policy has favoured community-based treatment over residential treatment services, and several residential treatment services have closed. Even so, the number of residential places has now returned to almost the levels seen around the year 2000. The 1980s and 1990s saw an increase in ‘kaupapa Māori’ services, but there has been little development in recent times.

District Health Boards are responsible for the planning and funding of alcohol and other drug treatment services in their areas, with direction and monitoring by central government.

New Zealand’s alcohol and other drug treatment strategy should take into account the findings of papers such as Adamson et al. The evidence in this paper helps build a clearer picture of the number, location, and types of services needed. It also has several implications for workforce development.

What does Adamson’s paper suggest to us?

First, where have the young, Caucasian, non–opioid users gone? (Pacific and Asian people were not mentioned in the survey). Māori treatment attendees were younger, as were amphetamine users. Problem use of substances usually starts when young, and New Zealanders use a variety of drugs if only because of our inconsistent supply of opioids.

What attracts someone to treatment for alcohol and other drug-dependency or problem use? To seek treatment, an individual needs to be aware that they have a problem and to consider that the benefits of continued substance use are outweighed by the problems they are encountering. Coming to this awareness can occur as someone ages, but is enabled by good point of first contact health and legal services that can detect the reasons behind a presentation and assist those with problematic substance misuse to think about the issue.

These services obviously need to be acceptable to youth. It could be that our services have not fully adjusted to changing youth culture and drug use patterns. Youth consumer networks, Pacific groups, Asian leaders, and recovering drug users may well be able to offer advice.

Second, substance-dependent clients come from a variety of backgrounds—some have never worked, some have little education ,and some have a criminal history. Their needs have to be analysed and appropriate habilitation offered. Those with complex presentations need more intensive treatment than community-based outpatient services can offer. The sooner there is an intervention in the course of development of a substance-misuse problem, the more likely a positive outcome can be achieved. Also, the longer a substance misuser attends a treatment process, the better the outcome. Follow-up or after-care is a core component to sustaining recovery.

Despite the welcome recent decision of the prison service to continue to offer opioid treatment services in prison, and a wider interest by Government in reducing prison numbers and re-offending by addressing substance misuse, good habilitation will have less chance of success in a prison than in a residential treatment service designed for that propose. Indeed, it could be that more residential treatment habilitation centres are needed as an alternative to prison.

Third, Māori are over-represented in the statistics Adamson describes. It is worrying to see that fewer Māori engage in the treatment process after the initial contact—the reasons need to be explored urgently. However, a success signalled in Adamson’s paper is the better retention rate of Māori in ‘kaupapa Māori’ services. That fact needs to be celebrated and considered alongside the recent political arguments suggesting less “special” treatment for Māori. This finding alone would suggest that the choice of a Māori alcohol and other drug habilitation service should be readily accessible or at the very least there should be increased Māori responsiveness in non dedicated Māori services. Indeed, further development of ‘kaupapa Māori’ services should be encouraged and supported.

Fourth, over the last few years we have seen a rise in amphetamine use. Amphetamines are not a new drug in New Zealand; they have been abused for at least the last 35 years. A fascinating finding in Adamson’s paper is that treatment-seeking amphetamine users mostly live in the North Island. This, together with the needs of under-represented groups in treatment such as the young and over-represented groups such as Māori, suggests that it is time for a rethink of the ideal service mix for alcohol and other drug treatment services in each region in collaboration with District Health Boards and local and regional advisors.

We congratulate Adamson and his colleagues on their research, at the very least it suggests that a “one size fits all” treatment service is not the way of the future.

Author information: Ross McCormick, Director, Goodfellow Unit, University of Auckland (and Chair of New Zealand Section of the Chapter of Addiction Medicine, RACP), Auckland; Christine Kalin, Chief Executive Officer, Odyssey House Drug Rehabilitation Programme, Auckland; Terry Huriwai, Project Manager, Matua Raki (Addiction Treatment Workforce Development Programme), Christchurch

Correspondence: Professor Ross McCormick, Goodfellow Unit, School of Population Health, University of Auckland, Private Bag, Auckland. Email: r.mccormick@auckland.ac.nz