Transcript rodtcompleteslidescombinedfinal

MAKING RECOVERY REAL:
THE PUBLIC HEALTH FUTURE OF
DRUG AND ALCOHOL TREATMENT
Bristol, 5 October 2012
Leeds, 11 October 2012
London, 15 October 2012
PROGRESS MADE
CHALLENGES AHEAD
Paul Hayes
Chief Executive, NTA
Drug use is down
Fewer young people are in treatment
More drug users are recovering
Younger people are doing better
People who use heroin are getting older
Crime is down
Policy evolution
2001
-
Harm
2005
-
Completion
2008
-
Abstinence
2010
-
Recovery
2012
-
Consensus
Strang
Everyone can, not everyone will
50 : 30 : 20
Recovery and, not recovery instead
Humility
Partnership
Optimism
Sketch map not satnav
Reasons to be cheerful
Evidence 
Consensus 
Money 
Track record 
LA leadership 
Integration 
PHE 
Politics 
Worries
£
NHS
Localism / stigma
Alcohol
Jobs and Houses
“New” drugs
Competence
Narrative of failure
Mission
“Give everyone who can, every chance to”
DRUGS AND ALCOHOL
AND NTA INTO PHE
Drugs & alcohol in public health
 Agenda will need to be championed, strategic partners
engaged
 Using the data, using the evidence, and making the arguments
 Drugs, alcohol, ATM and prevention …
NTA into PHE
 NDTMS & NATMS  Knowledge & Intelligence
 Central policy function  Health Improvement
 Local teams  Operations
 Expertise, support, tools continue to be available…
Alcohol Public Health Outcomes Framework indicator will be
based on the old NI39: estimates of the number of alcohol-related
hospital admissions (ArHA)
 Public Health Outcomes Framework – will be estimated
numbers of alcohol-related hospital admissions (ArHA)
 Prime Minister’s Implementation Unit – will monitor progress
against the same indicator
Successful completions and non re-presentations will now be
included (or is likely to be included) in the following indicator sets
 Public Health Outcome Framework – Successful completion
and non re-presentation (partnership only so far and
baselines produced)
 Prime Minister’s Implementation Unit – Successful completion
and non re-presentation (national with expected increases
month on month)
 PHE day one metric – Successful completions (national with
expected increases month on month)
 Social Justice Outcome Framework – Proposed successful
completion and non re-presentations
Drugs & alcohol in PHE
And the money…
The funding - current understanding
(O
rounded for ease)
Public Health Grant approx £2 billion in total
Pooled drug treatment budget
DH DIP funding
Young people’s substance misuse treatment
Local drug treatment spend
Alcohol
£400m
£ 60m
£ 25m
£160m
£???m
Substance misuse
component
of the
Public Health
Grant
Prison substance misuse treatment
£100m 
National
Commissioning
Board
HO DIP funding
£ 35m 
PCCs
Alcohol prevention and
treatment: now and in the
transition to Public Health
England
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alcohol strategy: what’s the problem
 Around 9 million people are drinking at levels which
are above the NHS guidelines
 Of these 2.2 million people (7% of men and 4% of
women) are most at risk of illness and death from
alcohol
 Within this, around 1.6 million have a possible
dependence on alcohol
 Alcohol harm costs the NHS about £3.5 billion per
year
 Alcohol-related crime £11 billion per year
 Lost productivity due to alcohol about £7.3 billion
alcohol strategy: what does government want
to achieve?
 change behaviour so people think it is not acceptable
to drink in ways that cause themselves or others harm
 reduce alcohol-fuelled violent crime
 reduce the number of adults drinking above NHS
guidelines
 reduce the number of people ‘binge drinking’
 reduce the number of alcohol related deaths and
 sustain reduction in both the numbers of 11-15 years
olds drinking and the amounts they consume
alcohol strategy: how
government plans to achieve it
Nationally:
• Introduction of a minimum unit price for
alcohol to stem the flow of cheap alcohol
• Consult on a ban on multi-buy price promotions
in shops
• A review, overseen by the Chief Medical Officer,
of the alcohol guidelines
TESCO EVERYDAY
VALUE LAGER 2%
(4X440ML)
2% ALC.
£1.00 (5.7P/100ML)
• A new density power to allow licensing
authorities to consider local health harms when
introducing Cumulative Impact Policies
• There will be an alcohol check within the NHS
Health Check for adults from April 2013
STELLA ARTOIS
(12X284ML).
£8.00 ANY 2 FOR
£15.00)
alcohol strategy: what is expected of local
areas?
 The strategy encourages local government, NHS, Police and Crime
Commissioners and other partners to work together to use their new
powers and responsibilities
 Local authorities and the new Health and Wellbeing Boards will be
required to use the ring fenced public health grant to address local public
health problems, including reducing alcohol related health harms
 Linking to funding via NHS Commissioning Board and CCGs for IBA and
hospital based services
 Whilst local action is led and delivered by local government and their
partners, PHE will be there to support this in every way it can
where we have been
Alcohol treatment system is dependent on local
prioritization
Relationship to drug treatment – a nationally driven
Government priority
Separate funding streams
No performance management of alcohol treatment.
Often locally integrated services
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a complex system
Supply
reduction
Child
protection
Outlet
Density
Community
treatment
IBA
Minimum
pricing
Acute
Sector
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Mental
Health
Prison
ATR
Probation
Demand
reduction
Residential
Adult
Safeguarding
but guidance exists
 Alcohol Learning Centre:
http://www.alcohollearningcentre.org.uk/
 NICE suite of alcohol guidance:
http://www.nice.org.uk/guidance/index.jsp?action=byID&o=11875
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a complex funding system
Supply
reduction
Child
protection
LA
LA/PHE
Outlet
Density
Minimum
pricing
LA-Licensing
Acute
Sector
CCG
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Mental
Health
CCG
Prison
NCB
IBA
CCG
LA/PHE
NCB
Community
Treatment
LA/PHE
ATR
Probation
NOMS
LA/PHE
Demand
reduction
Residential
LA/PHE
Adult
Safeguarding
LA
where we need to get to
• Quality Treatment System- Driven by local need
–
–
–
–
–
NICE and other guidance
Appropriately qualified staff
Appropriately commissioned
Inspected by CQC
NATMS
• Recovery focussed
– Mutual Aid
– Wider than the medical interventions
• Greater integration
– PHE for substance misuse
– Across multiple domains- A two way street.
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between now and April 2013
 Whilst local action is led and delivered by local government
and their partners, PHE will be there to support this in every
way it can after April
 Before then, support to commissioners and DsPH via regional
alcohol commissioner forums, focusing on the High Impact
Changes (Dept. of Health) and Alcohol Strategy priorities
 We will also be working with 14 areas in more depth, building
on the work of the Alcohol Improvement Programme
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regional alcohol support
 Regional alcohol networks will be promoted, based on existing
arrangements where in place
 themed events to draw in key stakeholders such as DsPH and
providers and focus on key delivery themes:
 IBA,
 hospital based services and
 NICE compliant specialist treatment
 Regional alcohol commissioner forums will be central to the
networks and focus on policy updates and priorities
 we will explore the use of action learning sets and web forums
(via the Alcohol Learning Centre)
 continued investment in existing alcohol services in all settings
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tools to support delivery
The following tools will be provided to all areas:
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Tools
Detail
Alcohol JSNA Support Pack
Publish end of October
Prevalence Service User Ratio
Expert Group held at the end of July agreed
methodology. PSUR will be shared with local areas as
part of the JSNA process in October 2012
Value for money /’Why invest’ in
alcohol services
Expert group held at end of July, with the aim of
circulating information in November 2012
more in-depth support to the 14 areas
 14 areas have been offered additional support and expertise from
alcohol programme managers
 Each region has at least one area
 Moving forwards this will help PHE shape its alcohol role
• Brighton and Hove
• Portsmouth
• Hammersmith and
Fulham
• Cambridgeshire
• Sandwell
• Birmingham
• Bristol
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•
•
•
•
•
•
Leeds
Bradford
Newcastle
Middlesbrough
Nottingham
x2 in the NW
MEDICATIONS IN RECOVERY:
RE-ORIENTATING DRUG
DEPENDENCE TREATMENT
Report of the Recovery Orientated Drug
Treatment Expert Group
Content
 The problem
 The chair’s interim report
 The group’s final report
 Implementation
The problem
2010 drug strategy:
“Substitute prescribing continues to
have a role to play in the treatment
of heroin dependence, both in
stabilising drug use and supporting
detoxification. Medically-assisted
recovery can, and does, happen…
However, for too many people
currently on a substitute
prescription, what should be the
first step on the journey to
recovery risks ending there. This
must change.”
Towards a solution
 NTA asked Professor John Strang
to chair a group to provide
guidance on the proper use of
medications to aid recovery
 Expert group comprised clinicians,
managers, service user
representatives, commissioners,
researchers and others
 Chair’s interim report published
July 2011
The interim report - outline
 Common ground in the group: strong body of evidence for
the effectiveness of opioid substitution treatment (OST) but
people in treatment could be better supported in their
recovery
 Existing guidance (NICE and orange book), and the
evidence on which it is based, already describes much of
what is best practice
 12 immediate steps that can be taken to improve the
recovery orientation of treatments that include prescribing
 But will also need a renewed emphasis on improving
people’s recovery
 Areas of work for the group’s final report
RODT - 12 immediate steps overview
Increase recovery-oriented ambition and progress by:
examining current practice to make sure there is balance between
overcoming dependence and reducing harm, and that recovery care
planning is good
checking clients are working towards abstinence and, as more people are
ready to come off, make sure they are properly supported
making sure clients are still getting real benefit from prescribing and, if
necessary, optimising treatment: adding psychosocials and/or getting dose
right
doing more to support people to recover: visible exits from treatment,
social networks, employment, housing
making sure staff are competent in all these interventions.
Strang J (2011) Recovery-orientated drug treatment an interim report by Professor John Strang,
chair of the expert group. NTA
The group’s final report
The treatment system’s achievements
Numbers in
treatment
The treatment system’s achievements
The treatment system’s achievements
Global HIV prevalence in people who inject drugs
The treatment system’s achievements
Drug treatment prevented an estimated 4.9m offences in 2010-11
The treatment system’s achievements
England drug misuse deaths
3,000
Projected deaths if 1993-2001
increase had continued
2,500
2,000
1390
1538 1510
1505
1313
1233
1,000
918
500
1800
1697
1,500
1025
1506 1456
1417
1731
1590
1625
1461
1097
788
0
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
The group’s final report
A lot done.
A lot more to do!
The group’s final report – July 2012
 High-quality treatment system
that substantially improves health
 Heroin is sticky
 Leaving treatment is important
but it isn’t recovery
 Lots of people haven’t recovered
 Done right, OST is effective but a
platform for recovery
 Don’t end it too early
 Some people recover fast, some
don’t – all need recovery support
The task set for the field by the group’s report
 “Well-delivered OST provides a platform of stability and
safety that protects people and creates the time and space
for them to move forward in their personal recovery
journeys. OST has an important and legitimate place within
a recovery orientated system of care.”
 “We need to ensure OST is the best platform it can be but
focus equally on the quality, range and purposeful
management of the broader package of care it sits within.”
McLellan and White commentary
Opioid maintenance and recovery-oriented systems of
care: it is time to integrate
“Recovery status is best defined by factors other than
medication status. Neither medication assisted treatment of
opioid addiction nor the cessation of such treatment by itself
constitute recovery. Recovery status instead hinges on
broader achievements in health and social functioning - with
or without medication support.”
A Thomas McLellan & William White
Avoid unintended consequences
Let’s be clear:
 This is about increasing recovery-oriented
ambition and progress for individuals and in
systems where there is not currently enough of it
 It is not about destabilising - to the point of
unacceptable risk - individuals who are deriving
benefit from OST.
Key to success
 A shared vision of recovery, and leadership
 Organisations & staff able to support and sustain change
 Staff who believe in the treatment they are delivering
 A structured programme with clear treatment goals
 Availability and range of OST medications
 Range and quality of psychosocial interventions
 Active referral to self help and mutual aid
 Links to recovery orientated community organisations
The evidence ...
 ... is good that OST:
 Retains people in treatment
 Suppresses illicit use of heroin
 Reduces crime
 Reduces the risk of BBV
 Reduces risk of death.
 ... is less persuasive that OST:
 Suppresses other drug use
 Improves physical and mental health
 Improves social reintegration of marginalised heroin users
 Promotes abstinence from all drugs.
Quality of pharmacological intervention
 Adequate dose
 Recognise increased metabolism in some
 Supervised consumption
 Contingency management to stop use on top
 Avoid therapeutic nihilism
What should services do?
 Do more
 Do it quick for those new in treatment,
and purposefully for all
 But avoid unintended consequences
Do more
Random treatment assignments
Methadone
Counselling
Other services
Level 1
n=29
Level 2
n=34
Level 3
n=36
>65mg
>65mg
>65mg
Regular
Regular
Employment
Family Therapy
Psychiatric Care
McLellan et al., (1997) Levels of Treatment in Methadone Maintenance Programs.
Treatment Research Institute
Target behaviours at six months
Do it quickly
 Greatest improvement seen during first three months
 Getting treatment right during this period vital to the
recovery process
Kakko J, Grönbladh L, Svanborg KD et al. (2007) Am J Psychiatry 2007; 164:797–803
And finally ...
“There is no justification for poor-quality treatment anywhere
in the system.
It is not acceptable to leave people on OST without actively
supporting their recovery and regularly reviewing the benefits
of their treatment.
Nor is it acceptable to impose time-limits on their treatment
that take no account of individual history, needs and
circumstances, or the benefits of continued treatment.
Treatment must be supportive and aspirational, realistic and
protective.”
Adaptive treatment
 Plan, review, optimise (measure)
 Phases:
 Engagement and stabilisation
 Preparation for change
 Active change
 Completion
 Layers (of intensity):
 Standard
 Enhanced
 Intensive
Challenge
 Implicit in undergoing treatment and also a role of
treatment
 Challenge in treatment:
 Difficult to initiate and maintain change to entrenched patterns
of drug-using behaviour
 Requires concerted effort and focus from everyone
 Especially difficult for those with little recovery capital
 Treatment services and staff create the therapeutic conditions
and optimism necessary
 Challenge of treatment
 Continued drug use or harmful drinking
 Ambivalence
Challenge ...
… will mean doing different things with people at different
points in the treatment journey:
goal setting
empathetic listening
exploring the impact and negative consequences of current
behaviour and the benefits of change
strategic use of problem recognition to amplify ambivalence
about their current position and behaviour
managing rewards and negative contingencies
involving social networks
Recovery support
 Peer-role models and peer support
 Employment support
 Family and social networks
 Housing support
 Improving well-being
 Post-treatment support
NDTMS- Core data set J
• Pharmacotherapy
• Psychosocial interventions
• Recovery support
• Post treatment recovery support
Staff equipped to achieve better outcomes
Evidence suggests:
 Workers who have clear techniques and belief in them
achieve better outcomes (goals and structure)
 Supervision and governance are key
 Outcomes are greatly influenced by the quality of the
working alliance
Wampold (2001), Bell (1998), Moos (2003)
Metacompetences
“Competent practitioners of psychosocial interventions implement
higher-order links between theory and practice in order to plan and
guide their practice and, where necessary, adapt an intervention to
individual needs.”

Metacompetences sit above technique competences

About understanding why and when to do something (and when not to
do it).
Pilling S, Hesketh K & Mitcheson L (2010) Routes to Recovery: Psychosocial Interventions For Drug Misuse - A
framework and toolkit for implementing NICE-recommended treatment interventions. London: BPS & NTA
Recommended interventions
 NICE & 2007 Clinical Guidelines:
 CM, BCT, CBT, CRA, SBNT, etc
 But ... research has been disappointing because it
neglects:
 relationships
 natural recovery
 therapists’ beliefs/theories
 patients’ views, etc.
 Focus on change processes
Orford J (2008) Asking the right questions in the right way: the need for a shift in research on psychological
treatments for addiction. Addiction103(6):875-85
Process elements common to effective treatment
 A knowledgeable, efficient, likeable and encouraging
helper who helps ...
 reinforce the feeling of need for change (e.g. encourage
‘discrepancy’)
 develop commitment to change (e.g. ‘pledges’, ‘change
statements’)
 develop self-efficacy (e.g. ‘self liberation’, ‘seeing the benefits’)
 build social support for change.
Orford J (2011)
Change processes, e.g. from MI






Self esteem
Competence/self-efficacy
Knowledge of problems
Knowledge of strategies to change
Concern
Clear goals
Miller & Rollnick (1991)
Implementation
• .. incorporation and use over time of a new treatment in routine
clinical practice (Manuel 2011)
• .. is the least researched component of translating evidencebased approaches into practice (Gotham, 2004)
• Requires synergy between:
•
•
•
•
•
Leadership
Culture of innovation
Governance
Training
Supervision
Phases of treatment: plan, review, optimise
Guidance and evidence
72
Commissioning and systems
Unintended consequences:
old
New
Integration
Pathways
Reintegration
Balanced systems- maintaining gains
Complexity, dual diagnosis and health
Medicines and new drugs
Service user’s voice
Creativity- ABCD, social enterprises, recovery communities
73
Guidance…….
74
75
Public health- broad and diverse, so is treatment.
77
Recovery support
Linking Treatment
with
Recovery Communities
(Medications in Recovery chapter 5)
Mark Gilman
Strategic Recovery Lead
National Treatment Agency
Slide 78
1980s ‘New Public Health’
3 Stage Response to Injecting Heroin Epidemic
1. Make Contact - ACCESS
2. Maintain Contact - RETENTION
3. Make
Positive Lifestyle Changes
Whole family and community based solutions
“You alone can do it but...
You CANNOT do it alone!”
THE SOCIAL CURE
SANITATION
Recovery and Public
Health 2012
Asset Based Community Development
A
B
C
D
Edwin Chadwick
John Snow
John McKnight
PUBLIC HEALTH PROBLEMS WITH SOCIAL SOLUTIONS
Treatment & Recovery Process
•
•
•
•
•
Engagement (e.g. NSP)
Preparation for Recovery
Active change process
Completion of treatment
Introduction to Recovery
Communities
Treatment & Recovery Eco Systems
CHANGE THIS...
Recovery
Communities
Treatment Community
TO THIS...
Treatment Community
Recovery Communities
In treatment but socially isolated
“All by myself...”
...SHOULD NEVER BE...
Identifying and changing social networks
Q. Who do you spend your time with in a typical week?
‘COMMUNITY AS METHOD’
SOCIAL BEHAVIOUR and NETWORK THERAPY
Rediscovering AA and Mutual Aid
Recovery since 1935
"The therapeutic value of one
addict helping another”
An Asset
with
“more than
2 million
members”
Wikipedia
“I cant but WE can”
“You alone can do it
but you cannot do it
alone”
Mutual Aid: A NICE Approved Asset
NICE Guidelines
Issue date: July 2007
Drug misuse
Psychosocial interventions
“Staff should routinely
provide people who misuse
drugs with information
about self-help groups.
These groups should
normally be based on 12step principles; for
example, Narcotics
Anonymous & Cocaine
Anonymous. “
NICE clinical guideline 51
Developed by the National Collaborating Centre for Mental Health
Dual carriageway to Recovery’s Social Cure...
 SMART Recovery
SMART Recovery
TWELVE STEP FACILITATION (TSF)
 NA, CA, AA…
R
E
C
O
V
E
R
Y
“12 Step Fellowships?”
• “Our clients don’t
like it, they won’t
go…”
• “12 step is not for
everyone…”
• “They’re just
swapping one
addiction for
another…”
CPTI
How it works in practice
Keep me alive
and out of
prison
Take me to a
mutual aid
meeting.
Connect me to
a recovery
community
NA, SMART…
Take me on as
a volunteer
taking other
people to
mutual aid
meetings and
connecting
them to
recovery
communities
Family and Social Networks
The addition of just one abstinent person to a drinker’s social network increased the
probability of abstinence in the next year by
27%
(Litt et al., 2009).
BEFORE
AFTER
Making Recovery Communities Visible
Challenging & Changing
5 ways to well being in Recovery
1. Connect… With people around you. Go to meetings (AA, NA, CA, SMART)
2. Be Active…do something, go for a walk, exercise, do anything.
3. Give… Do something for someone else. Volunteer.
4. Keep Learning… Try something new. Become a student of recovery?
5. Take Notice… Be curious. Be present. ‘The Power of Now’ (Ekhart Tolle)