1. An approach to disinvestment in the field of drug addiction treatment
A. Camposeragna, L. Amato, E. Parmelli, M. Davoli

2. Declaration No conflict of interest

3. Value for Money in Health Spending is a “mantra” given the recent economic downturn
NHS offers a wide range of interventions although some are uncertain to be beneficial for people's health
The great amount of available literature, sometimes contradictory, as well as its not easy access, contributes to the complexity of the decision-making process.

4. Effectiveness of 3000 treatments as reported in randomised clinical trial selected by Clinical Evidence. 2016

5. http://clinicalevidence. bmj

6. Background An intervention or a practice is low value if:
It is not clinically effective
it can be unsafe for sub-groups of patients (or all)
it is used inappropriately
Both for financial and ethical issues, it is beneficial reducing or stopping health care interventions that are considered low value.
An intervention or a practice is low value if:
is not clinically effective
it can be unsafe for sub-groups of patients (or all)
it is used inappropriately
Procedure from the working group of the Italian Ministry of Health whose aim was to identify which interventions in oncology could be eligible in a process of disinvestment (D’Amico, 2013)

7. Aims
To develop a simple and transparent evidence based process to identify a list of Low Value Interventions in the field of drug abuse treatment
To involve drug addiction professionals in focusing on what works and what does not
To contribute to an evidence-based drug policy making
Both for financial and ethical issues, it is beneficial reducing or stopping health care interventions that are considered low value.
An intervention or a practice is low value if:
is not clinically effective
it can be unsafe for sub-groups of patients (or all)
it is used inappropriately
Procedure from the working group of the Italian Ministry of Health whose aim was to identify which interventions in oncology could be eligible in a process of disinvestment (D’Amico, 2013)

8. Methods and tools
A transparent and simple evidence-based process along 3 steps:
a survey to identify a list of potential pharmacological and/or psychosocial treatment as LVIs for opiate, alcohol and psychostimulant dependence.
Sample: PTCs and TCs professionals (Turin and Rome areas)
Selection of a LVI suggested by at least 5 professionals (cut off)

9. Methods and tools
2. Provision of the evidence synthesis (Systematic reviews and indexed Guidelines) for each potential LVI identified
PICOs tool
Overlap between PICO structured LVIs and available evidence
3. A 5* expert panel (delphi technique) agrees on potential disinvestment of interventions, accordingly to provided evidence
* 2 very experienced professional (H-index), 1 policy maker (public health), 1 reviewer, 1 civil society

10. Disinvestment proposal
Operational Workflow
Identified LVI
Evidence?
STOP NO
Implication for research
YES
PICO Overlap?
Medium/Low
High
Expert Panel
Disagreement
Agreement
Disinvestment proposal

11. Results phase 1 Identification of potential LVIs
Sample: 70 respondents (82,9% Professionals working in PTCs)
Modal age group: years
Modal year of experience group: 20+ years
10 LVIs identified by more than 5 professionals
List of 10 identified LVIs (>5)
opiate addiciton:
2 pharmacological and 3 psychosocial
stimulant addiction:
1 pharmacolgical
Alcohol addiction:
3 pahrmacological and 1 pscyhosocial

12. Results phase 2 Evidence for clinical questions
NO evidence for the clinical question “Are two drop out episodes of an inpatient treatment (TC) predictive for further drop outs?”
Low/medium PICO overlap:
2 questions on alcohol
3 questions on opiates
Alcohol:
disulfiram for alcohol dependence treatment
Job placement as social support to substain alcohol abstinence
Opiates:
counselling sessions alone for heroin addiction treatment
BDZ for heroin detoxification
Long term (18+ month) inpatient treatment

13. Results phase 2 Clinical questions discussed
4 clinical questions are eligible to be submitted to panel of 5 experts:

14. Results phase 3 Potential disinvestment
Example: Do you agree on stopping GHB for alcohol detoxification?
Example: Do you agree on stopping GHB for alcohol detoxification?
I do not agree
I am uncertain
I do agree
The list integrated with evidence was sent to each of them.
For each of the 4 interventions they had to vote whether they agreed about disinvesting and explain their decisions.

15. Main Results
A general agreement on stopping pharmacological treatment with antidepressant for cocaine abuse was pointed out
There was no substantial agreement or high uncertainty about the other clinical questions
Need for further research is highlighted:
Psychosocial treatment (alone v/s pharmacological)
Long Term inpatient treatment (TCs)
BDZ for heroin users (alone or in association)
Disulfiram for alcohol addiction
No agreement (mainly uncertainity) on GHB, acamprosate, detox 30 gg can be useful in some case where managed withdrawal, or detoxification, is not in itself a treatment for dependence but detoxification remains a required first step for many forms of longer-term treatment
Further research for PICO’s with low overlap:
disulfiram per acohol
BDZ for opiate
Counselling
Job placement
Long termCT (18+ m)
Repeated inpatient treatment

16. Discussion
This small study confirms applicability of a grass root methodology
Professionals showed an high interest and motivation in being asked questions on LVIs
Need for more evidence based practices
Need for further research
Need for more involvement of policy makers

17. References