Hannah Lindsell Public Health England Medications in recovery: re-orientating drug dependence treatment How can we make Shared-care in Wandsworth more recovery orientated? Hannah Lindsell Public Health England

The group’s final report A lot done. A lot more to do! In a nutshell… The group’s final report A lot done. A lot more to do! 2

Everyone can recover, but not everyone will We don’t know who will Key principles Everyone can recover, but not everyone will We don’t know who will Give everyone the best chance for long term recovery Make leaving treatment and sustained recovery a hope for all from the beginning 3

Drug treatment has been a big success story Lives saved, harms reduced HIV rates amongst IV drug users are down Injecting rates amongst drug users are down Drug related deaths are down Crime has been much reduced

The problem 2010 drug strategy: “Substitute prescribing continues to have a role to play in the treatment of heroin dependence, both in stabilising drug use and supporting detoxification. Medically-assisted recovery can, and does, happen… However, for too many people currently on a substitute prescription, what should be the first step on the journey to recovery risks ending there. This must change.”

The group’s final report – July 2012 High-quality treatment system that substantially improves health Heroin is sticky Leaving treatment is important but it isn’t recovery Lots of people haven’t recovered Done right, OST is effective but a platform for recovery Don’t end it too early Some people recover fast, some don’t – all need recovery support

Avoid unintended consequences Let’s be clear: This is about increasing recovery-oriented ambition and progress for individuals and in systems where there is not currently enough of it It is not about destabilising - to the point of unacceptable risk - individuals who are deriving benefit from OST.

Key to success A shared vision of recovery, and leadership Organisations & staff able to support and sustain change Staff who believe in the treatment they are delivering A structured programme with clear treatment goals Availability and range of OST medications Range and quality of psychosocial interventions Active referral to self help and mutual aid Links to recovery orientated community organisations The effective components of OST require: Engaged stable clinical leadership that provide clear goals, maintains cohesion, focus and engagement of clinicians to sustain therapeutic conditions in which to optimise recovery An organisation and staff able to support and sustain change – motivated, with confidence in their skills, and a proportion themselves in recovery. Staff who believe in the tx they are delivering and have genuine concern and interest in those they are working with and respond empathetically. That they hold a belief in the clients capacity to change and have a sense of their role in fostering change. A structured programme that sets out tx goals providing direction and structure for people in treatment Range and quality od PSIs that enable emotional, social, and psychological wellbeing. Active referral to self help Availability and range of OST medications and supervised consumption that can be tailored to fit individual needs. Links to recovery orientated community organisations Tx should provide opportunities for individuals to fulfil pro-recovery social roles – peer mentors, SMART facilitators, which inspire other. Recovery choices are enhanced by exposure to others – so make recovery prominent

The evidence ... ... is good that OST: Retains people in treatment Suppresses illicit use of heroin Reduces crime Reduces the risk of BBV Reduces risk of death. ... is less persuasive that OST: Suppresses other drug use Improves physical and mental health Improves social reintegration of marginalised heroin users Promotes abstinence from all drugs.

What should services do? Do more, and review more frequently Do it quickly for those new in treatment, and purposefully for all Review those in long term treatment to check that they are still benefitting. If not, adjust treatment But avoid unintended consequences (exiting too soon and returning)

What shared care looks like in Wandsworth Nurse practitioner model GP Prescribing/Pharmacological interventions-325 48/325 = Non-Opiate 277/325 = Opiate Total number in treatment = 860 325/860 = 38% (LONDON average = 37%) Percentage of GP prescribing patients that successfully complete = 6% (LONDON average = 5%) Length of GP prescribing/Pharmacological intervention: 0-1yrs-76% 2-5 yrs- 24% 6+ years-0%

Recovery support-what does it look like in Wandsworth? Peer-role models and peer support  Employment support Family and social networks Housing support Mutual Aid-NA, CA, AA, Smart Recovery?

What are the challenges for Wandsworth Shared care? 15/42 practices engaged-expand? How? What are the barriers? Opportunity to review model/outcomes every year when you review the LES? How recovery orientated does the shared care system feel? Care Plan Audit of Shared Care clients? How often are Care Plan Review carried out with the Nurse practitioner, the client, the Pharmacist, the GP?

Further challenges? Low dose for 2-5yrs? Abstinence a realistic option? Is it offered? Greenwich model-brought in a Psychologist to work with this client group Is there an opportunity to segment the shared care population?

Any questions? ? Hannah.lindsell@phe.gov.uk 07795 036 473