Raising the Quality of Drug Treatment: Beyond National Standards
Organisational influences
Dr Ed DayUniversity of Birmingham &
Birmingham & Solihull Mental Health NHS Foundation Trust
June 2010
DRUGLINK – July & September 2009
‘...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’
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
Prescribing in Birmingham
Harm reduction
Prescribing medication reduces (but doesn’t 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
Does adding psychosocial therapy to OST improve outcomes?
• Ball and Ross’s 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
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 benefit 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)
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
Gateway to the
methadone
Counsellor or therapist
‘Social worker’
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%
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
Program Variations in Retention of Clients
Simpson, Joe, Broome, Hiller, Knight, & Rowan-Szal, 1997 (PAB)
BestProgram
PoorestProgram
DATOSDATOS1990s1990s
© 2007
Therapeutic EngagementTherapeutic Engagement
Ready for Change?Ready for Change?
Climate: Cohesion of Staff (Scale scores range = 10-50)
45 Programs (ITEP/BTEI Projects)
LowestLowest
HighestHighest
25%25%NormNorm
75%75%NormNorm
50% of 50% of ProgramsPrograms
UK
23
35
45
NTA ITEP/BTEI Projects (2006-07)
Program Needs, Functioning, & Innovation Implementation
TrainingTrainingWorkshop
A
WorkshopB
WorkshopC
6-9 Months6-9 MonthsAfterAfter
2-6 Months2-6 MonthsAfterAfter
ProgramProgramStaff &Staff &ClientsClients
ProgramProgramStaff &Staff &ClientsClients
FunctioningFunctioning(ORC/CEST-2)(ORC/CEST-2)
ProgramProgramStaffStaff
ProgramProgramStaffStaff
ChangesChanges(WAFU)(WAFU)
2-6 Months2-6 MonthsBeforeBefore
6-9 Months6-9 MonthsBeforeBefore
ProgramProgramStaff &Staff &ClientsClients
ProgramProgramStaff &Staff &ClientsClients
FunctioningFunctioning(ORC/CEST-1)(ORC/CEST-1)
ProgramProgramStaffStaff
ProgramProgramStaffStaff
NeedsNeeds(PTN)(PTN)
EvaluationEvaluation(WEVAL)(WEVAL)
StrategicStrategicPlanningPlanning
Quality of training & staff Quality of training & staff responsivenessresponsiveness predict predict
client functioningclient functioning
Level of program Level of program functioningfunctioning predicts staff predicts staff
responses to trainingresponses to training
Training needs & Training needs & readinessreadiness predict staff predict staff responses to trainingresponses to training
Simpson & Flynn, 2007 (Special Issue of JSAT)© 2007
Summary so far…
• OST can be effective• Key components not really clear• Prescribing side has improved• Psychosocial interventions add benefit, but
often poorly implemented
Moving forward: 3 steps to improving service quality
1 – Get our ‘treatment’ house in order
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
Make best use of resources we have
Better caseload management:• Low recovery capital / high’chaos’ 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
Birmingham Treatment
Effectiveness Initiative
November 2005 -
• Improve assessment process
• Improve care planning process
• Utilize node-link mapping to improve ‘counselling’ interventions
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
Low treatment readiness and high pressure for treatment
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 anxiety High 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 Communicatio
nCOCA/COSIS Manuals
Promoting Harm
Reduction
Reducing Alcohol
Consumption
Relapse Prevention
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’
• >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
Moving forward: 3 steps to improving service quality
1 – Get our ‘treatment’ house in order2 – Embrace the recovery agenda
– Link into existing recovery groups– Embrace recovery concepts and new ways of
working
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?
Conurbation No. of meetings Population Meetings / million
Weston-super-Mare 10 73,000 136
Bournemouth/Poole 28 383,713 73
Bristol 24 551,066 44
Brighton 20 461,181 43
Greater London 250 8,278,251 30
Edinburgh 13 452,194 29
Plymouth 7 243,795 29
Glasgow 31 1,168,270 27
Portsmouth 8 442,252 18
Nottingham 9 666,358 14
Kingston-upon-Hull 3 301,416 9
Greater Manchester 19 2,244,931 8
Liverpool/Merseyside 10 816,216 8
Middlesborough 3 365,323 8
Newcastle/Tyneside 5 879,996 6
Coventry 2 336,452 6
Cardiff 2 327,706 6
Sheffield 3 640,720 5
Leicester 2 441,213 5
Reading 2 369,804 5
Leeds 6 1,499,465 4
Stoke-on-Trent 1 362,403 4
Greater Birmingham 7 2,284,093 3
Medical ModelTreatment / ‘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 ModelRecovery 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 don’t 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
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
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
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
Moving forward: 3 steps to improving service quality
1 – Get our ‘treatment’ house in order2 – Embrace the recovery agenda
– Link into existing recovery groups– Embrace recovery concepts and new ways of
working
3 – Think ‘systems’
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