Managing alcohol to support recovery in mental health Overview of the national perspective Sean Meehan Alcohol & Drugs Public Health England East Midlands

2Overview of the national perspective specialist treatment providers, addictions psychiatry community safety, A&E, councillors health services, social services Alcohol – complex interests economic regeneration, the industry, the public who enjoy their right to drink alcohol Public health

Alcohol consumption over the years 3Overview of the national perspective

Alcohol consumption - Europe 4Overview of the national perspective

Drinking “At Risk” groups 5 Source: General Household Survey 2009 & mid-2009 population estimates (ONS) & Adult Psychiatric Morbidity Survey 2007 Overview of the national perspective

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8OVERVIEW OF THE NATIONAL PERSPECTIVE

9Overview of the national perspective

10Overview of the national perspective

There’s no magic bullet The problems caused by alcohol are multiple and varied. Our responses need to be multiple, targeting all aspects of alcohol-related harm They need to be joined-up and we must use our combined influence to negotiate across differing and often opposing agendas 11Overview of the national perspective

12Overview of the national perspective

PHE - Alcohol objectives and actions Primary Prevention (Universal action)  Increasing the awareness of the harmful effects of alcohol  Supporting and promoting the effective use of licensing legislation and local powers to create a safer drinking environment  Continuing to call for national MUP and leading the discussion on MUP, based on the evidence Secondary Prevention (Targeted Action)  Encouraging and supporting people who drink to do so within the lower risk levels Tertiary Prevention (Specialist Treatment)  Reducing the harmful impact of alcohol on individuals who already experience harm  Supporting improvements in treatment provision in line with NICE guidance 13Overview of the national perspective

What we want to see local areas deliver Primary Prevention (Universal action)  Local behaviour change campaigns that include alcohol  Local Responsibility Deals that include alcohol  DsPH effective use of their statutory powers in the Licencing Act  Local use of powers to restrict the irresponsible sale of alcohol Secondary Prevention (Targeted Action)  Implementation of the alcohol Health Check in line with guidance  Significant expansion of IBA in a range of settings, particularly primary care Tertiary Prevention (Specialist Treatment)  Effective use of hospital based alcohol services  Specialist treatment that is accessible and matched to local need  Treatment services that are good quality and compliant with NICE guidance 14Overview of the national perspective

15Overview of the national perspective

Alcohol’s relationship with mental health Alcohol alters brain chemistry Alcohol can increase anxiety and stress Link with depression Link to suicide, self harm and psychosis Alcohol can damage your memory Dual diagnosis 16OVERVIEW OF THE NATIONAL PERSPECTIVE

PbR Models – so far Historic “Block” Contracts Activity based PbR Outcome based PbR How NHS hospital were funded Historical costs Local NHS ‘family’ & budgets How NHS Acute Trusts funded today Health Resource Groups (HRGs) Tariffs PROMs Transfers risk to providers Experimental Recovery PbR Prisons Work Programme Immigration Overview of the national perspective17

Relationship between MH and alcohol clusters 18

Treatment clusters Alcohol Harm Clusters DependenceHealth Needs HoNOS / SARN scale Social Needs HoNOS / SARN scale Harmful & Mild Dependence AUDIT 16+ SADQ <15 Units/day <15 2. Non-accidental self- injury 3. Problem-drinking or drug-taking 4. Cognitive problems 5. Physical Illness 6. Hallucinations and delusions 7. Depressed Mood 8. Other Symptoms A. Agitated behaviour (historical) B. Repeat self-harm (historical) 1. Aggressive behaviour 9. Relationships 10. Activities of Daily Living 11. Living Conditions 12. Occupation and Activities 13. Strong unreasonable beliefs C. Safeguarding children D. Engagement E. Vulnerability Moderate Dependence AUDIT 20+ SADQ Units/day >15 Severe Dependence AUDIT 20+ SADQ >30 Units/day >30 Moderate & Severe + Complex Need AUDIT 20+ SADQ >15 Units/day >15 19

Packages of Care NICE guidance defines these packages ( NICE - STOP looking at care - service by service Detox, Residential Rehab, Day Treatment; etc NICE - START looking at packages / stages of care: Assessment & engagement Care planning & case management Withdrawal management Addressing physical and psychiatric co-morbidity Psychosocial interventions Pharmacotherapy Recovery, aftercare & reintegration 20Overview of the national perspective

Cluster 1 - Harmful drinking & mild dependence Assessment / Engagement / Motivational enhancement: Use AUDIT, SADQ/LDQ and units per day to determine dependence Determine level of risk and the presence of co-existing problems recorded by use of HONOS/SARN In-depth medical assessment will most likely not be necessary Deliver motivational enhancement to promote engagement Care Planning / Care co-ordination and Case management: A care plan Monthly follow-up for 3 months Withdrawal management: Most likely, there will not be a need to provide medical assistance But if so, will probably be met through outpatient management Psychosocial interventions: Brief advice should be given and assessed for effectiveness If needed, a package of less intensive (4 sessions) CBT/MET based treatment Pharmacotherapy: Prescribing for relapse prevention is not supported by evidence for this group. Recovery / Reintegration / Aftercare: Will depend on presenting need. Encouragement should be given to engage in self- help groups such as AA or SMART Recovery 21 Overview of the national perspective21

Cluster 2 - Moderate dependence (without complex needs) Assessment / Engagement / Motivational enhancement: Use AUDIT, SADQ/LDQ and units per day to determine dependence Determine level of risk and the presence of co-existing problems recorded by use of HONOS/SARN In-depth medical (physical & psychiatric) assessment may be necessary Deliver motivational enhancement to promote engagement Care Planning / Care co-ordination and Case management: A care plan Monthly follow-up for at least 6 months Withdrawal management: Most likely, withdrawal management can be met through outpatient management Post withdrawal assessment of mental health issues and cognitive function Psychosocial interventions: A package of less intensive CBT of up to 4 sessions should be offered If needed, 12 weeks of CBT based outpatient or day treatment programme may be required Pharmacotherapy: For relapse prevention - acamprosate or naltrexone (or disulfiram if indicated) for one year This should be delivered in conjunction with psychosocial interventions Recovery / Aftercare / Reintegration: Encouragement should be given to engage in self-help groups such as AA or SMART Recovery. Referral to employment services, assistance with housing and benefits may be required 22 Overview of the national perspective22

Cluster 3 - Severe dependence (without complex needs) 23 Overview of the national perspective23 Assessment / Engagement / Motivational enhancement: Use AUDIT, SADQ/LDQ and units per day to determine dependence Determine level of risk and the presence of co-existing problems recorded by use of HONOS/SARN In-depth medical (physical & psychiatric) assessment will be necessary Deliver motivational enhancement to promote engagement Care Planning / Care co-ordination and Case management: A care plan Case management lasting at least 12 months (frequent appointments in the first 3 months) Withdrawal management: Most likely inpatient care (but upon assessment may be met through outpatient care) Post withdrawal assessment of mental health issues and cognitive function Psychosocial interventions: A package of 12 weeks of CBT (outpatient or based in a day treatment programme) Residential rehabilitation of up to 12 weeks may be required Pharmacotherapy: For relapse prevention - acamprosate or naltrexone (or disulfiram if indicated) for one year. This should be delivered in conjunction with psychosocial interventions Physical and Psychiatric co-morbidity: These should be managed according to appropriate NICE guidelines Recovery / Aftercare / Reintegration: Encouragement should be given to engage in self-help groups such as AA or SMART Recovery. Referral to employment services, assistance with housing and benefits may be required.

Cluster 4 - Moderate / Severe dependence with complex needs Assessment / Engagement / Motivational enhancement: Use AUDIT, SADQ/LDQ and units per day to determine dependence Determine level of risk and the presence of co-existing problems recorded by use of HONOS/SARN In-depth medical (physical & psychiatric) assessment will be necessary Deliver motivational enhancement to promote engagement Care Planning / Care co-ordination and Case management: A care plan Case management lasting at least 12 months (frequent appointments in the first 6 months) Withdrawal management: Most likely inpatient care (but upon assessment may be met through outpatient care) Post withdrawal assessment of mental health issues and cognitive function Psychosocial interventions: A package of 12 weeks of CBT (based in a day treatment programme) Residential rehabilitation of up to 12 weeks may be required Pharmacotherapy: For relapse prevention - acamprosate or naltrexone (or disulfiram if indicated) for one year. This should be delivered in conjunction with psychosocial interventions Physical and Psychiatric co-morbidity: These should be managed according to appropriate NICE guidelines Recovery / Aftercare / Reintegration: Encouragement should be given to engage in self-help groups such as AA or SMART Recovery. Referral to employment services, assistance with housing and benefits may be required. 24 Overview of the national perspective24

Making recovery a reality in your community: A briefing for commissioners of mental health, drug and alcohol services 25OVERVIEW OF THE NATIONAL PERSPECTIVE Shared recovery Why recovery matters Who commissions what Opportunities for action