Rethinking substance misuse treatment
27 March 2026
A think piece by Bill Tidnam, Chief Executive
Substance misuse and its treatment have been a constant neighbour in my many years of working with people who have been affected by homelessness. But it has changed a great deal during that time.
At one stage, the offer for many people who used the day centre I worked in at the time was either no help, or the long-term and counterproductive prescription of tranquillisers to address symptoms of anxiety and depression. Alternatively, it was a punitive ‘treatment’ programme centred around a hospital inpatient detoxification, followed by a course of Antabuse medication. This was intended to discourage drinking by causing ‘distressing’ symptoms if alcohol was consumed.
I am talking about alcohol, because that, and the aforementioned tranquilisers, tended to be the most used drugs amongst the often quite socially conservative, usually male group who used most of the homelessness services in London at that time. The use of Antabuse has now largely been discontinued, not least because it was found to be carcinogenic. However, alternatives are still in use.
Different routes into treatment
There was a parallel, rather more fashionable treatment route, largely associated with opiate use. For the well-heeled, or fortunate, this meant months of residential rehabilitation. This was either funded by self or family, or in a few cases, by local authorities. These programmes moved beyond the treatment of the physical symptoms of drug or alcohol use. They also sought to address the root causes.
Both these approaches were supported for many by the twelve-step programmes of Alcoholics Anonymous, and later Narcotics Anonymous. For many, the simplicity and support of that system was what they needed, at the very least, to continue their fight against addiction.
However, for many, the absolutism of the twelve-step programme was too much. They wanted to do something about their drug or alcohol use and were concerned that it was out of hand. But they did not want to stop something that was the most important thing in their lives. This led to a more tolerant approach to substance use.
We began to talk more about ‘harm reduction’. This included an acceptance that safe use could be an acceptable alternative to abstinence, if only as a step on the road to that destination.
The shift towards harm reduction
Over time, our culture changes, and opiate drug use became far more democratised and more common. Part of the response to the HIV crisis amongst intravenous drug users in the 1990s was an application of this ‘harm management’ approach in this context.
The widespread use of the opiate substitute methadone was part of this shift. So too was the expectation that drug treatment should reach not just the minority who could afford it, or who had the commitment to persuade a council to fund residential treatment. It should also reach the majority who would still use drugs, but now less riskily.
Treatment in the current system
As we moved into the 2000s, and particularly into the period of austerity post-2010, definitions and approaches to treatment have continued to evolve. There is now an almost universal emphasis on the importance of ‘treatment’. This is defined as regular contact with a drug or alcohol worker, and adherence to community-based treatment, possibly a methadone ‘script’ and/or regular group work.
For many of the people we work with, this treatment does reduce the harm associated with illegal drugs. This includes the health consequences of unsafe use, contaminated or adulterated drugs, and the criminal activity needed to fund them. It may also support people to gain greater insight into their drug or alcohol use. By doing so, it can help to reduce or manage this.
The argument is that this approach is likely to have the most benefit for the most people. This includes the communities affected by the crime and anti-social behaviour associated with addictive drug use. There is much truth in this.
The limits of a management approach
However, there is a danger to this utilitarian approach.
People who are homeless and receiving community treatment are unlikely to benefit from the support of sympathetic and engaged friends and family. This is the ‘community’ which this type of support implies. Realistically, people will remain in environments where temptation and peer pressure are always present.
In these circumstances, treatment can end up managing some of the social impact of addiction. It may fail to treat the individual. There is a danger that we write off a whole group of people as not worth helping.
Believing in change
At Thames Reach, we believe in the capacity of the people we work with and for to make real and positive changes in their lives.
When I was writing this piece, I spoke to a couple of colleagues who have lived experience of addiction and who have made these changes. They told me that what made the difference for them was someone making decisions who was prepared to believe that they could change. That belief was matched by a willingness to invest in their future.
I also spoke to another colleague whose work is focused on the area between homelessness, health and addiction. They painted a clear and depressing picture of barriers to treatment. Some are bureaucratic, others are driven by how services are organised. There is also an underlying theme of lack of priority and funding in an area still seen by many as a ‘lifestyle choice’. Alongside this is an acceptance that reducing the harm associated with addiction is the best that can be hoped for.
The case for ambition
My colleagues show that we can and should expect to do more than this. If we are prepared to invest at the right time, people can change their lives. They can also go on to make a difference to many others. These are the worthwhile returns that investment in treatment can generate.
We need to be prepared to be ambitious. This applies not just to substance misuse treatment, but also to our belief in, and support for, real changes in people’s lives. This will be essential if we are to begin to achieve our mission of ending street homelessness.
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