Transcript Organisational influences - National Treatment Agency for

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
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’
‘...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’
‘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’
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
Stabilisation to abstinence
Reduces crime
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
Reduces risk of blood bore
viruses and accidental death
Goal is ultimately
detoxification
Prescribing medication reduces
(but doesn’t terminate) use of
heroin
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 12month 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
‘Social
worker’
Counsellor
or therapist
Time spent (in minutes) in last drug working
session
%
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%
Therapeutic
Activity
Best, Day et al (2009) Addiction Research & Theory 17(6) 678-687
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
DATOS
1990s
Best
Program
Therapeutic Engagement
Poorest
Program
Simpson, Joe, Broome, Hiller, Knight, & Rowan-Szal, 1997 (PAB)
© 2007
Climate: Cohesion of Staff
(Scale scores range = 10-50)
Ready for Change?
23
Lowest
25%
Norm
75%
Norm
50% of
Programs
35
Highest
UK
45 Programs (ITEP/BTEI Projects)
NTA ITEP/BTEI Projects (2006-07)
45
Program Needs, Functioning,
& Innovation Implementation
6-9 Months
Before
2-6 Months
Before
Strategic
Planning
Training
6-9 Months
After
Program
Staff
Program
Staff &
Clients
Changes
Functioning
Workshop
A
Workshop
B
Program
Staff
Program
Staff &
Clients
Needs
Functioning
Evaluation
(ORC/CEST-1)
(WEVAL)
(PTN)
2-6 Months
After
Training needs &
readiness predict staff
responses to training
Workshop
C
Level of program
functioning predicts staff
responses to training
Simpson & Flynn, 2007 (Special Issue of JSAT)
(WAFU)
(ORC/CEST-2)
Quality of training & staff
responsiveness predict
client functioning
© 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
Provide a workspace
for exploring
problems and
solutions
Train clearer and
more systematic
thinking
Create memory aids
for client and
counselor
Improve Therapeutic
Alliance
BENEFITS
OF MAPS
Provide a method for
getting “unstuck”
by providing new
ideas
Focus attention on
the topic at hand
Provide easy
reference to earlier
discussions
Useful structure for
clinical supervision
Low treatment
readiness and high
pressure for
treatment
Getting
Motivated to
Change
Low
motivation
Decisional
Balance Maps
Low
Problem
Solving
Attending
appointments
intervention
COCA/COSIS
Manuals
Improving
Communication
CM Strategies
Sleep
Disorders
CESI Graph
Goals of
Treatment
Care Planning
Mapping
Achievable Goals
High anger
High anxiety
High
depression
Managing Angry
Feelings
Relapse
Prevention
Developing
Social Support
Networks
Reducing
Alcohol
Consumption
Coping with
anxiety
Coping with
depression
Promoting
Harm
Reduction
Increasing
Pleasant
Activities
Exiting
Treatment
Assertiveness
& Drug
Refusal Skills
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 order
2 – 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 Model
Treatment / ‘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
Social Model
Recovery 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?
due on which day
Borkman T, 1998, JSAT 15(1) 37-48
Goal Planner
Problem Area
Drug and/or
alcohol use
Health (physical
& mental)
Social life &
friends
Relationships
(Partner or family)
Housing
Job/
Education
Money
Exercise
Legal & crime
Client:
Satisfaction
out of 10
Keyworker:
Date: __/__/__
What would have to change to increase my score out of 10?
Priority
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
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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 order
2 – 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