SMMGP - Substance Misuse Management Good Practice

Substance Misuse Management Good Practice

Supporting good practice in drug and alcohol treatment

Clinical & Policy Updates:
SMMGP Policy Update July-August 2012

NOTE: All the reports reviewed in this Update are available on the NTA website.

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Medications in recovery. Re-orientating drug dependence treatment

National Treatment Agency for Substance Misuse 2012

This is the long-awaited report from the Recovery-Orientated Drug Treatment group chaired by Dr John Strang of the National Addiction Centre. The aim of the group was to guide the drug treatment field on the proper and optimal use of medications to aid recovery. The report points out that there are an estimated 265,000 heroin addicts in England with around 165,000 of these currently in treatment and about 150,000 prescribed some form of opiate substitution therapy.

Initially, the report sets out a conceptual framework for promoting recovery. It emphasises that it is, or should be, an individual process or journey rather than a predetermined destination. The report touches on the concept of "recovery capital" and how this can be considered in terms of social, physical, human and cultural resources. The report then moves on to assessment and recovery care planning before suggesting the "phasing and layering" of interventions. It proposes care packages should be structured to deliver different interventions at different stages (phasing); then, different intensities are used according to need, choice, efficacy and progress toward recovery (layering). The report then goes on to suggest some of the practicalities of this approach - in the community, in prisons, and in residential and nonresidential settings.

The report touches on the issue of recovery support including: the use of peer role-models and peer support; employment support; the role of family and social networks contribution to recovery capital; housing issues; how to improve well-being; and, finally, post-treatment support. The last section of the report (and Appendix C by Dr James Bell) sets out the evidence on opiate substitution therapy and its effectiveness in promoting recovery.

Commentary

General practice will find little with which to argue in this report and there are many pointers towards better care. The report states in a number of different ways that there is simply no place for imposing time-limits on treatment with opiate substitution therapy and "arbitrarily or prematurely curtailing" opiate substitution therapy will not help sustain recovery and is not in the wider community interests. Equally, the need to ensure no one is left on opiate substitution therapy without appropriate review is also highlighted.

Whilst the phasing and layering of interventions will be a useful tool for practitioners and commissioners, it is important that this is not interpreted as a "painting by numbers" approach to care. The Royal College of Psychiatrists have this month cautioned against algorithms and decision making trees replacing clinical judgement in a payment by results system (Royal College of Psychiatrists (August 2012) Payment by results for mental health (England) Position Statement PS02/2012). A move towards 'mandatory' interventions based upon the stage at which someone is in treatment may limit choice for clients who do not always fit neatly into boxes, and potentially damage the therapeutic relationship which, time after time, is shown to be crucial to the effectiveness of interventions.

The report opens with the assertion that we have 165,000 out of 265,000 people with heroin addiction in treatment. What about the other 100,000? The focus of this report is on recovery and improving outcomes - but do we really think that these 100,000 have been waiting for a more recovery-orientated philosophy to engage with services? Perhaps, but we doubt it.

We know from the newly published From Access to Recovery report (see next item) that around onethird of people will drop out of treatment and not return. This suggests that there could be over 150,000 people with problems with heroin dependency for whom this report won't directly apply. A drug treatment approach that emphasises the need to "recover" may be interpreted by many users as enforced absolute abstinence.

The report doesn't consider this impact and it doesn't mention the need for "low threshold" services and other innovative ways, such as the provision of naloxone, that attempt to reduce the health and social consequences people with addictions experience.

Helpfully the report has avoided being drawn into ideological divisions, allowing opiate substitution therapy to take a sensible and pragmatic place as one of a range of options to help people recover.

This report is not the whole answer but it does give a model for moving forward. The biggest benefit of this report may be that it will help to draw a line under a divisive and, at times, bitter debate about drug policy in England.

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From access to recovery: analysing six years of drug treatment data

National Treatment Agency for Substance Misuse 2012

This short report sets out the data from the National Drug Treatment Monitoring System (NDTMS) which has identified 341,741 unique individuals treated over the six year period from 1 April 2005 to 31 March 2011. The NDTMS define successful treatment completion as someone deemed, in the eyes of a clinician, to be free of dependency from the drug for which they were being treated. Occasional use may be acceptable but cannot include anyone on a substitute prescription such as methadone.

The outcomes split rather conveniently into thirds: one-third will successfully complete; one-third dropped out and another third are still in treatment or returned. Since 2005-6 there has been a steady increase in the successful completion rate. There is a group of around 21,000 users (the reports describe them as "entrenched") who have been in continuous treatment - they represent 6% of those who have been through the treatment system.

The report notes the decline in the number of users needing treatment. The number of treatment-naive heroin users has fallen from around 48,000 in 2005-6 to just over 12,000 in 2010-11. Or, as the report puts it, from about one thousand per week to one thousand per month.

Commentary

One of the headline messages from this report is that one-third of those treated for addiction in the last three years have overcome their dependence. Overall, the report states that 85,303 individuals (25%) "successfully completed their treatment and overcame their addiction". None of this group returned to treatment so the report declares its confidence that these people have been able to sustain their recovery. The NDTMS does not provide any data on those people who have left treatment - the confident assertions that these people are fully recovered may be accurate but there is simply no data here (other than the fact they don't come back) to support that assumption.

As an aside, we would take issue with the word "entrenched" when applied to those 21,000 users who have been in continuous treatment. It's hard to imagine this being an appropriate term in any other chronic condition and speaks volumes for the lowlevel sniping at opiate substitution therapy that Strang's report has done much to put in an appropriate context. Medications in recovery: reorientating drug dependence treatment highlights there is simply no place for time-limited opiate substitution therapy. One feels that there is slight embarrassment about this 6% but it is simply the case that some people's recovery journey is longer than others. If these people were not statistics here in the NDTMS data then the evidence rather suggests they would be statistics in the mortality data. It's worth noting that the report gives the figure of 135,000 individuals in treatment being treated on any one day - this suggests that these "entrenched" users make up nearly 16% of the treatment population on a day-to-day basis.

We are delighted to see an improvement in successful completion rates. However, it is worth highlighting that the data are largely pre-2010. None of this is attributable to the 2010 Drug Strategy. This is particularly obvious when the figures for 2010-11 currently come out considerably lower than other years - the NTA have been at pains to point out (and it is fair comment) that this is due to the shorter time people have been in treatment. It takes time to get people through their treatment to the point at which they can be discharged. The effects of the 2010 Drug Strategy can't yet be discerned and the improvements (assuming they are real) we are seeing in completion rates are down to the policies in the years before the current government. They may even date back to the introduction of the NTA in 2001 and early policies such as the open and unconditional encouragement of people into treatment.

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The role of residential rehab in an integrated treatment system

National Treatment Agency for Substance Misuse 2012

There are a number of key messages from this report. It's clear that residential rehab should be an integral part of the treatment system and available to those who want it. The report highlights that despite accounting for 2% of people in adult drug treatment it takes up 10% of central funding. It is considerably more expensive than non-residential treatment services. Almost two-thirds of those who drop out will do so in the first few weeks. Outcomes are hugely variable with some rehabs where over 60% of their residents are overcoming dependency yet the lowest enable just 20% or fewer to overcome addiction.

An audit of rehab returns to NDTMS was undertaken in 2012 and the analysis of these was included in this report. The audit counted 4,166 rehab residents in 2010-11.

Commentary

As Paul Hayes, NTA Chief Executive, points out in this report, the right placement at the right time can be a powerful and cost-effective step for many individuals. The audit data have confirmed that rehab is not some separate and distinct entity, remote from other treatment options. Individuals move between community services to rehab and back again. Residential rehab is currently just one option in an integrated system. Integration can be useful but it does pose some risks for rehab as it is expensive and it makes it harder for commissioners to distinguish between components in a complex system. It is clear from the report that there are some issues with residential rehab, and reading between the lines, these need to be addressed to secure its future in a cost-conscious healthcare landscape driven by outcome measures.

The report is at pains to highlight that "all services must demonstrate value for money in an increasingly outcomes-focused healthcare landscape". Like the notional surgeon who won't take on high risk cases as it may damage his mortality data, we could be left with a residential rehab system which will become risk averse as they strive to maintain good numbers. Yet, it seems likely that the best use of residential rehab is to manage complex cases where the extra cost is then justified. There is an underlying tension here - one that payment by results can distort; residential rehab will need careful management to ensure local commissioners don't spend unwisely or inappropriately sweep it away as an expensive and unaffordable option.