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Raising the Quality of Drug Treatment: Beyond National Standards Organisational influences Dr Ed Day University of Birmingham & Birmingham & Solihull Mental Health NHS Foundation Trust June 2010

Raising the Quality of Drug Treatment: Beyond National Standards Organisational influences Dr Ed Day University of Birmingham & Birmingham & Solihull Mental

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Page 1: Raising the Quality of Drug Treatment: Beyond National Standards Organisational influences Dr Ed Day University of Birmingham & Birmingham & Solihull Mental

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

Page 2: Raising the Quality of Drug Treatment: Beyond National Standards Organisational influences Dr Ed Day University of Birmingham & Birmingham & Solihull Mental

DRUGLINK – July & September 2009

Page 3: Raising the Quality of Drug Treatment: Beyond National Standards Organisational influences Dr Ed Day University of Birmingham & Birmingham & Solihull Mental

‘...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’

Page 4: Raising the Quality of Drug Treatment: Beyond National Standards Organisational influences Dr Ed Day University of Birmingham & Birmingham & Solihull Mental

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

Page 5: Raising the Quality of Drug Treatment: Beyond National Standards Organisational influences Dr Ed Day University of Birmingham & Birmingham & Solihull Mental

Prescribing in Birmingham

Page 6: Raising the Quality of Drug Treatment: Beyond National Standards Organisational influences Dr Ed Day University of Birmingham & Birmingham & Solihull Mental

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

Page 7: Raising the Quality of Drug Treatment: Beyond National Standards Organisational influences Dr Ed Day University of Birmingham & Birmingham & Solihull Mental

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

Page 8: Raising the Quality of Drug Treatment: Beyond National Standards Organisational influences Dr Ed Day University of Birmingham & Birmingham & Solihull Mental

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)

Page 9: Raising the Quality of Drug Treatment: Beyond National Standards Organisational influences Dr Ed Day University of Birmingham & Birmingham & Solihull Mental

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

Page 10: Raising the Quality of Drug Treatment: Beyond National Standards Organisational influences Dr Ed Day University of Birmingham & Birmingham & Solihull Mental

Gateway to the

methadone

Counsellor or therapist

‘Social worker’

Page 11: Raising the Quality of Drug Treatment: Beyond National Standards Organisational influences Dr Ed Day University of Birmingham & Birmingham & Solihull Mental

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%

Page 12: Raising the Quality of Drug Treatment: Beyond National Standards Organisational influences Dr Ed Day University of Birmingham & Birmingham & Solihull Mental

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

Page 13: Raising the Quality of Drug Treatment: Beyond National Standards Organisational influences Dr Ed Day University of Birmingham & Birmingham & Solihull Mental

Program Variations in Retention of Clients

Simpson, Joe, Broome, Hiller, Knight, & Rowan-Szal, 1997 (PAB)

BestProgram

PoorestProgram

DATOSDATOS1990s1990s

© 2007

Therapeutic EngagementTherapeutic Engagement

Page 14: Raising the Quality of Drug Treatment: Beyond National Standards Organisational influences Dr Ed Day University of Birmingham & Birmingham & Solihull Mental

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)

Page 15: Raising the Quality of Drug Treatment: Beyond National Standards Organisational influences Dr Ed Day University of Birmingham & Birmingham & Solihull Mental

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

Page 16: Raising the Quality of Drug Treatment: Beyond National Standards Organisational influences Dr Ed Day University of Birmingham & Birmingham & Solihull Mental

Summary so far…

• OST can be effective• Key components not really clear• Prescribing side has improved• Psychosocial interventions add benefit, but

often poorly implemented

Page 17: Raising the Quality of Drug Treatment: Beyond National Standards Organisational influences Dr Ed Day University of Birmingham & Birmingham & Solihull Mental

Moving forward: 3 steps to improving service quality

1 – Get our ‘treatment’ house in order

Page 18: Raising the Quality of Drug Treatment: Beyond National Standards Organisational influences Dr Ed Day University of Birmingham & Birmingham & Solihull Mental

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

Page 19: Raising the Quality of Drug Treatment: Beyond National Standards Organisational influences Dr Ed Day University of Birmingham & Birmingham & Solihull Mental

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

Page 20: Raising the Quality of Drug Treatment: Beyond National Standards Organisational influences Dr Ed Day University of Birmingham & Birmingham & Solihull Mental

Birmingham Treatment

Effectiveness Initiative

November 2005 -

• Improve assessment process

• Improve care planning process

• Utilize node-link mapping to improve ‘counselling’ interventions

Page 21: Raising the Quality of Drug Treatment: Beyond National Standards Organisational influences Dr Ed Day University of Birmingham & Birmingham & Solihull Mental

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

Page 22: Raising the Quality of Drug Treatment: Beyond National Standards Organisational influences Dr Ed Day University of Birmingham & Birmingham & Solihull Mental

Low treatment readiness and high pressure for treatment

Page 23: Raising the Quality of Drug Treatment: Beyond National Standards Organisational influences Dr Ed Day University of Birmingham & Birmingham & Solihull Mental
Page 24: Raising the Quality of Drug Treatment: Beyond National Standards Organisational influences Dr Ed Day University of Birmingham & Birmingham & Solihull Mental

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

Page 25: Raising the Quality of Drug Treatment: Beyond National Standards Organisational influences Dr Ed Day University of Birmingham & Birmingham & Solihull Mental

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’

Page 26: Raising the Quality of Drug Treatment: Beyond National Standards Organisational influences Dr Ed Day University of Birmingham & Birmingham & Solihull Mental

• >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

Page 27: Raising the Quality of Drug Treatment: Beyond National Standards Organisational influences Dr Ed Day University of Birmingham & Birmingham & Solihull Mental

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

Page 28: Raising the Quality of Drug Treatment: Beyond National Standards Organisational influences Dr Ed Day University of Birmingham & Birmingham & Solihull Mental

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?

Page 29: Raising the Quality of Drug Treatment: Beyond National Standards Organisational influences Dr Ed Day University of Birmingham & Birmingham & Solihull Mental

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

Page 30: Raising the Quality of Drug Treatment: Beyond National Standards Organisational influences Dr Ed Day University of Birmingham & Birmingham & Solihull Mental

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

Page 31: Raising the Quality of Drug Treatment: Beyond National Standards Organisational influences Dr Ed Day University of Birmingham & Birmingham & Solihull Mental

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

Page 32: Raising the Quality of Drug Treatment: Beyond National Standards Organisational influences Dr Ed Day University of Birmingham & Birmingham & Solihull Mental

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

Page 33: Raising the Quality of Drug Treatment: Beyond National Standards Organisational influences Dr Ed Day University of Birmingham & Birmingham & Solihull Mental

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

Page 34: Raising the Quality of Drug Treatment: Beyond National Standards Organisational influences Dr Ed Day University of Birmingham & Birmingham & Solihull Mental

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’

Page 35: Raising the Quality of Drug Treatment: Beyond National Standards Organisational influences Dr Ed Day University of Birmingham & Birmingham & Solihull Mental

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