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Raising the Quality of Drug Treatment: Beyond National Standards Organisational influences Dr Ed Day University of Birmingham & Birmingham & Solihull Mental.

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Presentation on theme: "Raising the Quality of Drug Treatment: Beyond National Standards Organisational influences Dr Ed Day University of Birmingham & Birmingham & Solihull Mental."— Presentation transcript:

1 Raising the Quality of Drug Treatment: Beyond National Standards Organisational influences Dr Ed Day University of Birmingham & Birmingham & Solihull Mental Health NHS Foundation Trust June 2010

2 DRUGLINK – July & September 2009

3 ...we can move away from the ubiquity of the diagnosis and the prescribing pad...the client is entitled to expect more than a bucket and straw, and a chat with a harassed drug worker The system of drug treatment, if effective, has the collateral damage effect of institutionalising dependence in substance users who may have naturally matured out or recovered...we rush users through the process to a methadone script because that is what is available and... we offer little in the way of psychosocial support

4 What works? Treatment system in England has evolved to facilitate rapid access and maximize retention in treatment Opioid substitution treatment (OST) is the predominant form of treatment in UK Methadone (and buprenorphine) shown to be effective in systematic reviews NICE has endorsed both drugs – fixed dose MMT has superior levels of treatment retention and opiate use to placebo or no treatment – higher fixed doses of MMT more effective than lower fixed doses – fixed dose MMT reduces mortality, HIV risk behaviour and levels of crime compared with no therapy

5 Prescribing in Birmingham

6 Harm reduction Prescribing medication reduces (but doesnt terminate) use of heroin Reduces crime Reduces risk of blood bore viruses and accidental death Stabilisation to abstinence By reducing craving and preventing withdrawal OST frees the patient from preoccupation with obtaining illicit opioids, thus enabling them to make use of available psychosocial interventions Goal is ultimately detoxification

7 Does adding psychosocial therapy to OST improve outcomes? Ball and Rosss study of methadone programs (1990) McLellan et al (1993) conducted a 24-week clinical trial involving 3 treatment groups: – methadone with minimal counselling – methadone plus moderate (i.e. more intensive) counselling – methadone plus enhanced counselling (including on-site medical/psychiatric, employment, and family therapy) 6-month abstinence rates higher for the group receiving enhanced counselling compared with the moderate counselling group NTORS – patients in MMT who received drug problem counselling sessions had significantly better heroin and cocaine outcomes than those receiving no counselling

8 Does adding psychosocial therapy to OST improve outcomes? Amato et al (2009): 28 trials and 2945 participants Number abstinent at the end of follow up (5 trials) and continuous weeks of abstinence (2 trials) showed a benet in favour of the associated treatment When compared to standard maintenance treatment, the addition of any psychosocial treatment produced no benefit in – treatment retention (RR 1.02, 95%CI 0.97 to 1.07) – use of opiate during the treatment (RR 0.86, 95%CI 0.65 to 1.13) – psychiatric symptoms (MD 0.02, 95% CI-0.19 to 0.23) – number of participants still in treatment at the end of follow-up (RR 0.91, 95%CI 0.77 to 1.06) Psychosocial Treatment for Drug Misuse (NICE, 2008): evidence for – Contingency management for people in OST (strongly and consistently associated with longer, continuous periods of abstinence during treatment and abstinence at 6- and 12- month follow-up) – Behavioural-couples therapy and family-based interventions (associated with reductions in illicit drug use)

9 Does adding psychosocial therapy to OST improve outcomes? Therapist Effects Variation in therapist competence/performance is single largest contributor to variance in outcomes of psychosocial interventions Differences of over 100% in outcomes between therapists may exist - cannot be accounted for by service user variables (e.g. severity or comorbidity), setting or intervention variables Reviews implementation conclude that quality of training and supervision is variable and rarely includes meaningful training This problem is compounded by high rates of clinician turnover and a lack of objective assessment of clinician or service performance and outcomes

10 Gateway to the methadone Counsellor or therapist Social worker

11 Time spent (in minutes) in last drug working session Best, Day et al (2009) Addiction Research & Theory 17(6) 678-687 Therapeutic Activity % of clients ever discussed % discussed in last session Complementary therapies 10.5%3.2% Alcohol interventions 9.3%4.4% Harm reduction 68.3%29.4% Motivational enhancement 1.5%1.2% Relapse prevention 66.3%34.0% Other structured interventions 22.7%14.0% Care planning 78.8%21.2%

12 Does adding psychosocial therapy to OST improve outcomes? Organisational Factors Large differences in the treatments offered by individual services DATOS showed many methadone programmes do not provide sufficient range or intensity of counselling to meet their patients needs Big differences in the effectiveness of different treatment programs Some services do a better job of engaging and retaining patients, and such services also show better gains in psychosocial functioning by their patients

13 Program Variations in Retention of Clients Simpson, Joe, Broome, Hiller, Knight, & Rowan-Szal, 1997 (PAB) Best Program Poorest Program DATOS 1990s © 2007 Therapeutic Engagement

14 Ready for Change? Climate: Cohesion of Staff (Scale scores range = 10-50) 45 Programs (ITEP/BTEI Projects) Lowest Highest 25%Norm75%Norm 50% of Programs UK 23 35 45 NTA ITEP/BTEI Projects (2006-07)

15 Program Needs, Functioning, & Innovation Implementation Training Workshop A Workshop B Workshop C 6-9 Months After 2-6 Months After Program Staff & ClientsProgram Clients Functioning(ORC/CEST-2)ProgramStaffProgramStaffChanges(WAFU) 2-6 Months Before 6-9 Months Before Program Staff & ClientsProgram Clients Functioning(ORC/CEST-1) ProgramStaffProgramStaff Needs(PTN) Evaluation(WEVAL) StrategicPlanning Quality of training & staff responsiveness predict client functioning Level of program functioning predicts staff responses to training Training needs & readiness predict staff responses to training Simpson & Flynn, 2007 (Special Issue of JSAT) © 2007

16 Summary so far… OST can be effective Key components not really clear Prescribing side has improved Psychosocial interventions add benefit, but often poorly implemented

17 Moving forward: 3 steps to improving service quality 1 – Get our treatment house in order

18 Enhance training / supervision of treatment staff Improving Access to Psychological Therapies (IAPT) Stepped care - relatively brief low-intensity interventions for mild to moderate problems, and high-intensity treatment for more severe problems BPS framework for implementing NICE-recommended treatment interventions in OST Low-intensity interventions - delivered by drug workers, and may be drug-specific (motivational and treatment engagement tools to reduce substance misuse) or targeted at common mental health problems High-intensity interventions - formal psychological therapies delivered by a specialist psychological therapist and targeted only at individuals with the most severe problems Allows training of staff to be targeted and assessed against a national standard

19 Make best use of resources we have Better caseload management : Low recovery capital / highchaos harm reduction approach Higher recovery capital promote abstinence-based, recovery pathway Requires better assessment, good understanding of full range of client problems, clear idea of tools available and measurement of their application

20 Birmingham Treatment Effectiveness Initiative November 2005 - Improve assessment process Improve care planning process Utilize node-link mapping to improve counselling interventions

21 BENEFITS OF MAPS Provide a workspace for exploring problems and solutions Improve Therapeutic Alliance Focus attention on the topic at hand Train clearer and more systematic thinking Create memory aids for client and counselor Provide a method for getting unstuck by providing new ideas Provide easy reference to earlier discussions Useful structure for clinical supervision

22 Low treatment readiness and high pressure for treatment


24 Care Planning Mapping Achievable Goals CESI Graph Exiting Treatment Increasing Pleasant Activities Assertiveness & Drug Refusal Skills Managing Angry Feelings Goals of Treatment Attending appointments intervention Coping with anxiety High anxietyHigh depression Coping with depression Getting Motivated to Change Low motivation Decisional Balance Maps Low Problem Solving CM Strategies High anger Developing Social Support Networks Sleep Disorders Improving Communication COCA/COSIS Manuals Promoting Harm Reduction Reducing Alcohol Consumption Relapse Prevention

25 Enhance the structure of community prescribing Problems with how our prescribing services are structured? Community pharmacies Easy access Primary care role USA-style maintenance treatment: – Barriers to program entry – 7-day per week attendance – On-site dispensing – Compulsory counselling and other wrap-around services

26 >1 year in MMT and not employed Required to get 20 hours of employment Given 2/12 to secure this If they failed – more intensive weekly counselling for 8hours/week for 10 weeks Counselling focus was resistance to employment goal 21 day taper of methadone until goal reached 75% got employment for at least 1 month + 78% employed at 6 month follow-up More drug use if failed

27 Moving forward: 3 steps to improving service quality 1 – Get our treatment house in order 2 – Embrace the recovery agenda – Link into existing recovery groups – Embrace recovery concepts and new ways of working

28 UK Substance Misuse Treatment Workers Attitudes to Twelve-Step Self-Help Groups Day E, Gaston R, Furlong E, Murali V, Copello A. Journal of Substance Abuse Treatment 2005 29;321-327 Staff feel that they know enough about 12-Step treatment and the AA/NA Fellowship Less than half are likely to recommend their clients to make use of these services Overall attitudes to the 12-Step process are mixed (but mildly positive) Over half actively disagree with 6 of the 12 Steps Contrast with surveys reporting the views of US treatment staff (Forman et al 2001, Humphreys 1997) How do we explain this?

29 ConurbationNo. of meetingsPopulationMeetings / million Weston-super-Mare1073,000136 Bournemouth/Poole28383,71373 Bristol24551,06644 Brighton20461,18143 Greater London2508,278,25130 Edinburgh13452,19429 Plymouth7243,79529 Glasgow311,168,27027 Portsmouth8442,25218 Nottingham9666,35814 Kingston-upon-Hull3301,4169 Greater Manchester192,244,9318 Liverpool/Merseyside10816,2168 Middlesborough3365,3238 Newcastle/Tyneside5879,9966 Coventry2336,4526 Cardiff2327,7066 Sheffield3640,7205 Leicester2441,2135 Reading2369,8045 Leeds61,499,4654 Stoke-on-Trent1362,4034 Greater Birmingham72,284,0933

30 Medical Model Treatment / Treatment Planning Assessments/diagnostic tests based on objective criteria completed by MDT Decide which aspects of treatment patient is lacking understanding in Alcohol, drug, medical or psychiatric needs Rarely includes job skills development or accommodation issues Limited patient involvement Documentation of treatment plan/progress notes consumes 25-40% of staff time Demands of assessment, treatment planning, documentation etc so extensive that a strategy developed to remind staff which documentation is due on which day Social Model Recovery Process / Recovery Planning Residents fill out recovery plans and are responsible for their development, revision, and implementation Staff and peers have a guiding and teaching role and dont direct Newcomers self-identify their own problems No diagnostic batteries of standardised instruments Master recovery plan within 30 days – medium-range objectives (6-12 months) Where are you in terms of 10 domains? – physical, employment, finances, legal, family, social life, drinking, personal, education and spiritual Where would you like to be? What can you do within each domain to reach your objectives? Borkman T, 1998, JSAT 15(1) 37-48

31 Keyworker: Date: __/__/__Client: Problem Area Satisfaction out of 10 What would have to change to increase my score out of 10? Priority Drug and/or alcohol use Health (physical & mental) Social life & friends Relationships (Partner or family) Housing Legal & crime Exercise Money Job/ Education Goal Planner

32 Developing recovery volunteer programs Recovery community volunteers can – Offer themselves as living proof of the reality of recovery – Share their recovery status, and if appropriate, their recovery story – Serve as a recovery lifestyle consultant, sharing practical tips on living as a person in recovery within your family, workplace or community – Help paid staff guide the client into relationships with one or more communities of recovery – Provide support and advocacy to each client/family to facilitate access to needed recovery services – Provide face-to-face telephone and e-mail communications for monitoring, recovery coaching and possible early re-intervention White & Kurtz (2006) Recovery: Linking Addiction Treatment & Communities of Recovery

33 The Recovery Coach Motivator and cheerleader Ally and confidant Truth-teller Role model and mentor Problem-solver Resource broker Advocate Community organizer Lifestyle consultant A friend

34 Moving forward: 3 steps to improving service quality 1 – Get our treatment house in order 2 – Embrace the recovery agenda – Link into existing recovery groups – Embrace recovery concepts and new ways of working 3 – Think systems

35 3. Think systems Work out what you want from treatment Use outcome measurements effectively – in a motivational style Refine ways of commissioning a system Tackle the wider social issues

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