Bristol, 5 October 2012 Leeds, 11 October 2012 London, 15 October 2012 MAKING RECOVERY REAL: THE PUBLIC HEALTH FUTURE OF DRUG AND ALCOHOL TREATMENT

Paul Hayes Chief Executive, NTA PROGRESS MADE CHALLENGES AHEAD

Drug use is down

Fewer young people are in treatment

More drug users are recovering

Younger people are doing better

People who use heroin are getting older

Crime is down

Policy evolution 2001-Harm 2005-Completion 2008-Abstinence 2010-Recovery 2012-Consensus

Strang Everyone can, not everyone will 50 : 30 : 20 Recovery and, not recovery instead Humility Partnership Optimism Sketch map not satnav

Reasons to be cheerful Evidence Consensus Money Track record LA leadership Integration PHE Politics

Worries £ NHS Localism / stigma Alcohol Jobs and Houses New drugs Competence Narrative of failure

Mission Give everyone who can, every chance to

DRUGS AND ALCOHOL AND NTA INTO PHE

Drugs & alcohol in public health Agenda will need to be championed, strategic partners engaged Using the data, using the evidence, and making the arguments Drugs, alcohol, ATM and prevention …

NTA into PHE NDTMS & NATMS Knowledge & Intelligence Central policy function Health Improvement Local teams Operations Expertise, support, tools continue to be available…

Alcohol Public Health Outcomes Framework indicator will be based on the old NI39: estimates of the number of alcohol-related hospital admissions (ArHA) Public Health Outcomes Framework – will be estimated numbers of alcohol-related hospital admissions (ArHA) Prime Ministers Implementation Unit – will monitor progress against the same indicator

Successful completions and non re-presentations will now be included (or is likely to be included) in the following indicator sets Public Health Outcome Framework – Successful completion and non re-presentation (partnership only so far and baselines produced) Prime Ministers Implementation Unit – Successful completion and non re-presentation (national with expected increases month on month) PHE day one metric – Successful completions (national with expected increases month on month) Social Justice Outcome Framework – Proposed successful completion and non re-presentations

Drugs & alcohol in PHE And the money…

The funding - current understanding ( rounded for ease) Public Health Grant approx £2 billion in total Pooled drug treatment budget £400m Substance misuse DH DIP funding £ 60mcomponent Young peoples substance misuse treatment £ 25m of the Local drug treatment spend £160m Public Health Alcohol £???m Grant Prison substance misuse treatment £100m National Commissioning Board HO DIP funding £ 35m PCCs

Alcohol prevention and treatment: now and in the transition to Public Health England 21

alcohol strategy: whats the problem Around 9 million people are drinking at levels which are above the NHS guidelines Of these 2.2 million people (7% of men and 4% of women) are most at risk of illness and death from alcohol Within this, around 1.6 million have a possible dependence on alcohol Alcohol harm costs the NHS about £3.5 billion per year Alcohol-related crime £11 billion per year Lost productivity due to alcohol about £7.3 billion

alcohol strategy: what does government want to achieve? change behaviour so people think it is not acceptable to drink in ways that cause themselves or others harm reduce alcohol-fuelled violent crime reduce the number of adults drinking above NHS guidelines reduce the number of people binge drinking reduce the number of alcohol related deaths and sustain reduction in both the numbers of years olds drinking and the amounts they consume

alcohol strategy: how government plans to achieve it Nationally: Introduction of a minimum unit price for alcohol to stem the flow of cheap alcohol Consult on a ban on multi-buy price promotions in shops A review, overseen by the Chief Medical Officer, of the alcohol guidelines A new density power to allow licensing authorities to consider local health harms when introducing Cumulative Impact Policies There will be an alcohol check within the NHS Health Check for adults from April 2013 STELLA ARTOIS (12X284ML)STELLA ARTOIS (12X284ML). £8.00 ANY 2 FOR £15.00) ANY 2 FOR £15.00 TESCO EVERYDAY VALUE LAGER 2% (4X440ML) 2% ALC. £1.00 (5.7P/100ML)

alcohol strategy: what is expected of local areas? The strategy encourages local government, NHS, Police and Crime Commissioners and other partners to work together to use their new powers and responsibilities Local authorities and the new Health and Wellbeing Boards will be required to use the ring fenced public health grant to address local public health problems, including reducing alcohol related health harms Linking to funding via NHS Commissioning Board and CCGs for IBA and hospital based services Whilst local action is led and delivered by local government and their partners, PHE will be there to support this in every way it can

where we have been Alcohol treatment system is dependent on local prioritization Relationship to drug treatment – a nationally driven Government priority Separate funding streams No performance management of alcohol treatment. Often locally integrated services 26

a complex system 27 Outlet Density Minimum pricing IBA Child protection Prison Acute Sector ATR Probation Mental Health Adult Safeguarding Residential Community treatment Supply reduction Demand reduction

but guidance exists Alcohol Learning Centre: NICE suite of alcohol guidance: 28

a complex funding system 29 Outlet Density Minimum pricing LA-Licensing IBA CCG LA/PHE NCB Child protection LA LA/PHE Prison NCB Acute Sector CCG ATR Probation NOMS LA/PHE Mental Health CCG Adult Safeguarding LA Residential LA/PHE Community Treatment LA/PHE Supply reduction Demand reduction

where we need to get to Quality Treatment System- Driven by local need – NICE and other guidance – Appropriately qualified staff – Appropriately commissioned – Inspected by CQC – NATMS Recovery focussed – Mutual Aid – Wider than the medical interventions Greater integration – PHE for substance misuse – Across multiple domains- A two way street. 30

between now and April 2013 Whilst local action is led and delivered by local government and their partners, PHE will be there to support this in every way it can after April Before then, support to commissioners and DsPH via regional alcohol commissioner forums, focusing on the High Impact Changes (Dept. of Health) and Alcohol Strategy priorities We will also be working with 14 areas in more depth, building on the work of the Alcohol Improvement Programme 31

32 Regional alcohol networks will be promoted, based on existing arrangements where in place themed events to draw in key stakeholders such as DsPH and providers and focus on key delivery themes: IBA, hospital based services and NICE compliant specialist treatment Regional alcohol commissioner forums will be central to the networks and focus on policy updates and priorities we will explore the use of action learning sets and web forums (via the Alcohol Learning Centre) continued investment in existing alcohol services in all settings regional alcohol support

The following tools will be provided to all areas: ToolsDetail Alcohol JSNA Support PackPublish end of October Prevalence Service User RatioExpert Group held at the end of July agreed methodology. PSUR will be shared with local areas as part of the JSNA process in October 2012 Value for money /Why invest in alcohol services Expert group held at end of July, with the aim of circulating information in November tools to support delivery

more in-depth support to the 14 areas areas have been offered additional support and expertise from alcohol programme managers Each region has at least one area Moving forwards this will help PHE shape its alcohol role Leeds Bradford Newcastle Middlesbrough Nottingham x2 in the NW Leeds Bradford Newcastle Middlesbrough Nottingham x2 in the NW Brighton and Hove Portsmouth Hammersmith and Fulham Cambridgeshire Sandwell Birmingham Bristol Brighton and Hove Portsmouth Hammersmith and Fulham Cambridgeshire Sandwell Birmingham Bristol

MEDICATIONS IN RECOVERY: RE-ORIENTATING DRUG DEPENDENCE TREATMENT Report of the Recovery Orientated Drug Treatment Expert Group

Content The problem The chairs interim report The groups final report Implementation

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.

Towards a solution NTA asked Professor John Strang to chair a group to provide guidance on the proper use of medications to aid recovery Expert group comprised clinicians, managers, service user representatives, commissioners, researchers and others Chairs interim report published July 2011

The interim report - outline Common ground in the group: strong body of evidence for the effectiveness of opioid substitution treatment (OST) but people in treatment could be better supported in their recovery Existing guidance (NICE and orange book), and the evidence on which it is based, already describes much of what is best practice 12 immediate steps that can be taken to improve the recovery orientation of treatments that include prescribing But will also need a renewed emphasis on improving peoples recovery Areas of work for the groups final report

RODT - 12 immediate steps overview Increase recovery-oriented ambition and progress by: examining current practice to make sure there is balance between overcoming dependence and reducing harm, and that recovery care planning is good checking clients are working towards abstinence and, as more people are ready to come off, make sure they are properly supported making sure clients are still getting real benefit from prescribing and, if necessary, optimising treatment: adding psychosocials and/or getting dose right doing more to support people to recover: visible exits from treatment, social networks, employment, housing making sure staff are competent in all these interventions. Strang J (2011) Recovery-orientated drug treatment an interim report by Professor John Strang, chair of the expert group. NTA

The groups final report

The treatment systems achievements Numbers in treatment

The treatment systems achievements

Global HIV prevalence in people who inject drugs

The treatment systems achievements Drug treatment prevented an estimated 4.9m offences in

The treatment systems achievements

The groups final report A lot done. A lot more to do!

The groups final report – July 2012 High-quality treatment system that substantially improves health Heroin is sticky Leaving treatment is important but it isnt recovery Lots of people havent recovered Done right, OST is effective but a platform for recovery Dont end it too early Some people recover fast, some dont – all need recovery support

The task set for the field by the groups report Well-delivered OST provides a platform of stability and safety that protects people and creates the time and space for them to move forward in their personal recovery journeys. OST has an important and legitimate place within a recovery orientated system of care. We need to ensure OST is the best platform it can be but focus equally on the quality, range and purposeful management of the broader package of care it sits within.

McLellan and White commentary Opioid maintenance and recovery-oriented systems of care: it is time to integrate Recovery status is best defined by factors other than medication status. Neither medication assisted treatment of opioid addiction nor the cessation of such treatment by itself constitute recovery. Recovery status instead hinges on broader achievements in health and social functioning - with or without medication support. A Thomas McLellan & William White

Avoid unintended consequences Lets 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 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.

Quality of pharmacological intervention Adequate dose Recognise increased metabolism in some Supervised consumption Contingency management to stop use on top Avoid therapeutic nihilism

What should services do? Do more Do it quick for those new in treatment, and purposefully for all But avoid unintended consequences

Do more Level 1 n=29 Level 2 n=34 Level 3 n=36 Methadone>65mg CounsellingRegular Other servicesEmployment Family Therapy Psychiatric Care Random treatment assignments McLellan et al., (1997) Levels of Treatment in Methadone Maintenance Programs. Treatment Research Institute

Target behaviours at six months

Do it quickly Greatest improvement seen during first three months Getting treatment right during this period vital to the recovery process Kakko J, Grönbladh L, Svanborg KD et al. (2007) Am J Psychiatry 2007; 164:797–803

And finally... There is no justification for poor-quality treatment anywhere in the system. It is not acceptable to leave people on OST without actively supporting their recovery and regularly reviewing the benefits of their treatment. Nor is it acceptable to impose time-limits on their treatment that take no account of individual history, needs and circumstances, or the benefits of continued treatment. Treatment must be supportive and aspirational, realistic and protective.

Adaptive treatment Plan, review, optimise (measure) Phases: Engagement and stabilisation Preparation for change Active change Completion Layers (of intensity): Standard Enhanced Intensive

Challenge Implicit in undergoing treatment and also a role of treatment Challenge in treatment: Difficult to initiate and maintain change to entrenched patterns of drug-using behaviour Requires concerted effort and focus from everyone Especially difficult for those with little recovery capital Treatment services and staff create the therapeutic conditions and optimism necessary Challenge of treatment Continued drug use or harmful drinking Ambivalence

Challenge... … will mean doing different things with people at different points in the treatment journey: goal setting empathetic listening exploring the impact and negative consequences of current behaviour and the benefits of change strategic use of problem recognition to amplify ambivalence about their current position and behaviour managing rewards and negative contingencies involving social networks

Recovery support Peer-role models and peer support Employment support Family and social networks Housing support Improving well-being Post-treatment support

NDTMS- Core data set J Pharmacotherapy Psychosocial interventions Recovery support Post treatment recovery support

Staff equipped to achieve better outcomes Evidence suggests: Workers who have clear techniques and belief in them achieve better outcomes (goals and structure) Supervision and governance are key Outcomes are greatly influenced by the quality of the working alliance Wampold (2001), Bell (1998), Moos (2003)

Metacompetences Competent practitioners of psychosocial interventions implement higher-order links between theory and practice in order to plan and guide their practice and, where necessary, adapt an intervention to individual needs. Metacompetences sit above technique competences About understanding why and when to do something (and when not to do it). Pilling S, Hesketh K & Mitcheson L (2010) Routes to Recovery: Psychosocial Interventions For Drug Misuse - A framework and toolkit for implementing NICE-recommended treatment interventions. London: BPS & NTA

Recommended interventions NICE & 2007 Clinical Guidelines: CM, BCT, CBT, CRA, SBNT, etc But... research has been disappointing because it neglects: relationships natural recovery therapists beliefs/theories patients views, etc. Focus on change processes Orford J (2008) Asking the right questions in the right way: the need for a shift in research on psychological treatments for addiction. Addiction103(6):875-85

Process elements common to effective treatment A knowledgeable, efficient, likeable and encouraging helper who helps... reinforce the feeling of need for change (e.g. encourage discrepancy) develop commitment to change (e.g. pledges, change statements) develop self-efficacy (e.g. self liberation, seeing the benefits) build social support for change. Orford J (2011)

Change processes, e.g. from MI Self esteem Competence/self-efficacy Knowledge of problems Knowledge of strategies to change Concern Clear goals Miller & Rollnick (1991)

Implementation.. incorporation and use over time of a new treatment in routine clinical practice (Manuel 2011).. is the least researched component of translating evidence- based approaches into practice (Gotham, 2004) Requires synergy between: Leadership Culture of innovation Governance Training Supervision

Phases of treatment: plan, review, optimise

72 Guidance and evidence

73 Commissioning and systems Unintended consequences: old New Integration Pathways Reintegration Balanced systems- maintaining gains Complexity, dual diagnosis and health Medicines and new drugs Service users voice Creativity- ABCD, social enterprises, recovery communities

74 Guidance…….

75

77 Public health- broad and diverse, so is treatment.

Slide 78 Recovery support Linking Treatment with Recovery Communities (Medications in Recovery chapter 5) Mark Gilman Strategic Recovery Lead National Treatment Agency

1. Make Contact - ACCESS 2. Maintain Contact - RETENTION 3. Make Positive Lifestyle Changes Whole family and community based solutions You alone can do it but... You CANNOT do it alone! THE SOCIAL CURE 1980s New Public Health 3 Stage Response to Injecting Heroin Epidemic

Recovery and Public Health 2012 SANITATION Asset Based Community Development ABCDABCD Edwin Chadwick John Snow John McKnight PUBLIC HEALTH PROBLEMS WITH SOCIAL SOLUTIONS

Treatment & Recovery Process Engagement (e.g. NSP) Preparation for Recovery Active change process Completion of treatment Introduction to Recovery Communities

Treatment & Recovery Eco Systems Treatment Community Recovery Communities Treatment Community Recovery Communities CHANGE THIS... TO THIS...

All by myself... In treatment but socially isolated...SHOULD NEVER BE...

Identifying and changing social networks Q. Who do you spend your time with in a typical week? COMMUNITY AS METHOD

SOCIAL BEHAVIOUR and NETWORK THERAPY

"The therapeutic value of one addict helping another An Asset with more than 2 million members Wikipedia Rediscovering AA and Mutual Aid Recovery since 1935 I cant but WE can You alone can do it but you cannot do it alone

Issue date: July 2007 NICE clinical guideline 51 Developed by the National Collaborating Centre for Mental Health Drug misuse Psychosocial interventions NICE Guidelines Staff should routinely provide people who misuse drugs with information about self-help groups. These groups should normally be based on 12- step principles; for example, Narcotics Anonymous & Cocaine Anonymous. Mutual Aid: A NICE Approved Asset

TWELVE STEP FACILITATION (TSF) Dual carriageway to Recoverys Social Cure... RECOVERYRECOVERY SMART Recovery NA, CA, AA…

12 Step Fellowships? Our clients dont like it, they wont go… 12 step is not for everyone… Theyre just swapping one addiction for another… CPTI

How it works in practice Keep me alive and out of prison Take me to a mutual aid meeting. Connect me to a recovery community NA, SMART… Take me on as a volunteer taking other people to mutual aid meetings and connecting them to recovery communities

Family and Social Networks BEFORE AFTER The addition of just one abstinent person to a drinkers social network increased the probability of abstinence in the next year by 27% (Litt et al., 2009).

Making Recovery Communities Visible

Challenging & Changing 5 ways to well being in Recovery 1.Connect… With people around you. Go to meetings (AA, NA, CA, SMART) 2.Be Active…do something, go for a walk, exercise, do anything. 3.Give… Do something for someone else. Volunteer. 4.Keep Learning… Try something new. Become a student of recovery? 5. Take Notice… Be curious. Be present. The Power of Now (Ekhart Tolle)