REVIEW OF THE NEED TO EXPAND DRUG AND ALCOHOL REHABILITATION SERVICES IN THE ACT FINAL MARCH 2012

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1 REVIEW OF THE NEED TO EXPAND DRUG AND ALCOHOL REHABILITATION SERVICES IN THE ACT FINAL MARCH 2012 Dr Rod MacQueen Mr Andrew Biven Commissioned by the Alcohol and Other Drug Policy Unit, Health Directorate ACT

2 Acknowledgments The authors wish to acknowledge the assistance of consumers, ACT alcohol, tobacco and other drug treatment and support services (ATODTSS) and the Alcohol, Tobacco and Other Drug Association ACT (ATODA) who generously gave their time to assist with the preparation of this report. The authors also acknowledge the work of Mr Ray Lovett, Dr Phyll Dance, Dr Jill Guthrie and Ms Katherine Thurber (researchers based with Australian Institute of Aboriginal and Torres Strait Islander Studies [AIATSIS] and the Australian National University s National Centre for Epidemiology and Population Health [NCEPH]) who undertook the community consultations to coordinate and report on the consumer input to the Review. The authors also acknowledge the work of the Alcohol and Other Drug Policy Unit, Health Directorate, in assisting with the literature review and undertaking the analysis of quantitative data for this report. Dr Rod MacQueen, Addiction specialist based at Lyndon Withdrawal Unit, Orange, NSW Mr Andrew Biven, Independent Consultant with a background in the field of drug and alcohol rehabilitation in Australia Page 2 of 92

3 Table of Contents Acknowledgments... 2 Table of Contents Executive Summary Introduction: Purpose and Scope of the Review Purpose of Review Scope of Review Methodology Population and epidemiological analyses of the prevalence of alcohol and other drug misuse Population of the ACT The extent and nature of the use of alcohol, tobacco and other drugs (ATOD) in the ACT and the harms associated with that use Observations on population and epidemiological data Review of the International and Local Evidence Relating to Outcomes in the Drug Rehabilitation Area What is drug and alcohol rehabilitation? What are desired outcomes of drug and alcohol rehabilitation? Factors associated with improved outcomes Good practice in service delivery Treatment Elements and program characteristics Treatment elements and client groups Planning for optimal rehabilitation outcomes Current profile of those utilising ACT residential rehabilitation services and related childcare services and a profile of those employed by alcohol, tobacco and other drug treatment and support services Principal drug of concern for those accessing residential rehabilitation services and Alcohol and Drug Services Health Directorate Main treatment type for those accessing residential rehabilitation services and Alcohol and Drug Services Health Directorate Length of Stay for those accessing withdrawal and residential rehabilitation services Completion rates for those accessing withdrawal and residential rehabilitation services Page 3 of 92

4 5.5 Flow of clients between Alcohol and Drug Services Health Directorate and residential rehabilitation services The ACT Drug Diversion Programs Services that provide care and / or support for children whose parents are accessing a drug treatment and/or support program in the ACT Workforce Qualification and Remuneration Profile Analysis Analysis of Consultation Data with the ACT ATOD Sector Process General observations and comments Specific observations and comments Specific observations and comments from meeting with the Alcohol, Tobacco and Other Drug Association ACT (ATODA) Consumer feedback study Background Results Conclusions Review Findings and Conclusions Recommendations References Appendix 1: ACT Review of Residential Rehabilitation Services Site Visits Appendix 2: Methodology Adopted for Consumer Consultation Appendix 3: Survey instrument consumer feedback Page 4 of 92

5 1. Executive Summary In 2011, the ACT Government undertook to complete a review of the need to expand drug and alcohol rehabilitation services in the ACT. Undertaking a review of rehabilitation services was also a recommendation of the ACT Government Estimates Standing Committee in Two consultants, Dr Rod MacQueen and Mr Andrew Biven, with a history in the field of drug and alcohol rehabilitation, were engaged to work on the Review, the primary focus of which is on residential rehabilitation services. To accomplish its aim of reviewing the need to expand alcohol and drug rehabilitation services in the ACT, the Review examines a range of evidence. This includes: evidence on the need for drug rehabilitation services in the ACT; international and local evidence of what contributes to good outcomes from drug rehabilitation services; consumer input on drug rehabilitation services in the ACT; and data on current drug rehabilitation service provision and usage patterns. In addition, site visits were conducted to ACT alcohol, tobacco and other drug treatment and support services (ATODTSS) including residential rehabilitation services in the ACT from December 5-9, These visits involved discussion with service providers about service delivery and planning, to assess current service provision arrangements and future needs. Mr Raymond Lovett, Dr Phyll Dance, Dr Jill Guthrie and Ms Katherine Thurber (researchers based with Australian Institute of Aboriginal and Torres Strait Islander Studies [AIATSIS] and the Australian National University s National Centre for Epidemiology and Population Health [NCEPH]) were contracted to undertake consumer consultations to provide the consumer input to the Review. Overall, the report identifies existing arrangements in the ACT and evidence of their efficacy, together with identifying service gaps and opportunities to strengthen service delivery. Key themes emerging from the evidence base and reflected in the consumer feedback include that good models of care are ones that are sufficiently flexible so as to enable individual needs to be matched with appropriate treatment programs. In particular, these refer to: program length; program structure and intensity; and recognising the special needs of women and men, those from culturally diverse backgrounds including Aboriginal and Torres Strait Islander peoples, parents caring for children, and those with co-occurring mental health problems. Key evidence emerging from the data analysis on current service provision, site visits and consumer consultations suggests that: - The ACT has a high level of effective communication and cooperation amongst ACT alcohol, tobacco and other drug treatment and support services (ATODTSS). Services demonstrate good ability to reflect on their service delivery capacity. Planning is well underway towards a number of the rehabilitation services extending their intake criteria to adopt a more flexible approach to program delivery, and capitalising upon benefits of joint delivery of programs and co-location of services. The capacity of services to deliver quality programs has been enhanced significantly over the past five years through major investments in building workforce development, particularly in conjunction with the Alcohol, Tobacco and Other Drug Association ACT (ATODA); - There is no strong evidence of a need to increase the number of residential rehabilitation beds in the ACT; Page 5 of 92

6 - There is evidence of barriers for many people to accessing treatment and support services, including residential rehabilitation programs, which need to be removed; - Fewer adults than could be expected are accessing and transitioning from the tertiary level clinical drug treatment service offered by Alcohol and Drug Service (ADS) Health Directorate to ACT residential rehabilitation programs, given most adults in residential rehabilitation programs are likely to be people with severe alcohol and / or other drug problems. Key areas of service gap / need identified by the Review are: - Access to non-residential rehabilitation programs; - Access to residential and non-residential rehabilitation programs catering for those on Opioid Maintenance Therapy (OMT) and those with special needs such as those from culturally and linguistically diverse backgrounds and Aboriginal and Torres Strait Islander Peoples; - Engagement in sporting activities, vocational education and employment both during rehabilitation programs and when people leave programs; - A tertiary level clinical outpatient service offering assessment and treatment for those with complex ATOD problems (other than those seeking assistance in relation to OMT) and a strengthened consultation/ liaison service provided by an interdisciplinary team; - Subsidised support to childcare services for parents accessing ATODTSS. In light of these service gaps and needs, the Review makes 9 key recommendations: 1. Improve access to a range of alcohol, tobacco and other drug treatment and support services (ATODTSS) and improve treatment outcomes for clients by: - providing referrers, prospective clients and family members / friends of those with alcohol, tobacco and other drug (ATOD) problems, with more detailed information about the eligibility criteria, structure and content of programs and expectations of those who participate in programs; - considering opportunities for joint initiatives between services and with external partners in order to offer a greater range of rehabilitation program options, reduce barriers to access and achieve greater efficiencies including the provision of: o o o o o day programs; out of regular business hours (e.g. evenings, weekends) programs; programs which accommodate both those on Opioid Maintenance Treatment (OMT) and those wishing to reduce off OMT; smoking reduction and cessation programs for staff and clients; and sporting activities, vocational education and employment - tailoring programs to address the special needs to target populations such as people with ATOD related disabilities, people affected by criminal activity and disadvantage, people from culturally and linguistically diverse backgrounds, including migrants and refugees and people from gay, lesbian, bi-sexual, sex and Page 6 of 92

7 gender diverse communities. 2. Strengthen human resource management practices across rehabilitation programs including: improving the staffing of some programs by employing: o o o more staff, better qualified and experienced staff, and / or better remunerated staff; seeking recurrent funding for programs currently funded only on a short term basis; and further strengthening access to and participation in local, jointly-delivered high quality and diverse ACT alcohol, tobacco and other drug (ATOD) sector training in conjunction with the Alcohol, Tobacco and Other Drug Association ACT (ATODA). 3. Enhance access to primary health care, mental health services and subsidised childcare services to improve the health and wellbeing of clients of rehabilitation programs and their families. 4. Develop an Infrastructure Redevelopment Fund as a systematic, long-term response to ageing infrastructure at some rehabilitation programs and investigate opportunities for resource sharing amongst services, such as buses and recreational equipment. 5. Increase consumer, carer and family member participation in service planning and delivery to improve the quality of rehabilitation programs. 6. Strengthen the delivery of culturally competent and culturally secure services for Aboriginal and Torres Strait Islander people. 7. Strengthen the Alcohol and Drug Services (ADS), Health Directorate by: establishing an outpatient clinic offering assessment and treatment for people with complex alcohol, tobacco and other drug (ATOD) problems to complement services currently offered by the Alcohol and Drug Services Opioid Treatment Service and Inpatient Unit; expanding the current 10 bed inpatient bed unit to provide improved treatment capacity into the future for those with complex alcohol, tobacco and other drug (ATOD) problems ; ensuring the Young Adult Mental Health Unit is able to work effectively with young people with alcohol, tobacco and other drug (ATOD) problems; providing tertiary level clinical drug treatment services on an outreach into the North of Canberra (including clinical assessment, prescriptions and / or supervised dispensing of opioid maintenance treatment (OMT) for people with complex alcohol, tobacco and other drug (ATOD) problems; ensuring an ADS interdisciplinary program (including nurse practitioners) offers consultation liaison Page 7 of 92

8 advice, professional development support, and clinical outreach services to assist medical practitioners including general practitioners, DIRECTIONS ACT s Althea Clinic and other alcohol, tobacco and other drug treatment and support services (ATODTSS); and expand the role of the Intake Line to provide drug counselling services and to better promote its role and the role of the range of ACT alcohol, tobacco and other drug treatment and support services (ATODTSS) available to key referrers such as general practitioners. 8. Improve intake, transition and aftercare support for people seeking to enter and leave alcohol, tobacco and other drug treatment and support services (ATODTSS) including assertive waiting list support. 9. Establish clear governing arrangements to guide the implementation and evaluation of supported recommendations from this report. Page 8 of 92

9 2. Introduction: Purpose and Scope of the Review 2.1 Purpose of Review In 2011, the ACT Government undertook to complete a review of the need to expand drug and alcohol rehabilitation services. Undertaking a review of rehabilitation services was also a recommendation of the ACT Government Estimates Standing Committee in Scope of Review The primary focus of the review is residential rehabilitation services including the: 38 bed rehabilitation program for men and women operated by the Salvation Army Canberra Recovery Service; 44 bed rehabilitation programs for families and single adults operated by Karralika Programs Inc.; 14 bed withdrawal and rehabilitation program for young people up to the age of 18 years operated by the Ted Noffs Foundation; 10 bed withdrawal and rehabilitation program for adults at Arcadia House operated by DIRECTIONS ACT; and 13 bed support program for single women and women with children including women who are planning to attend and / or have completed a supervised withdrawal program operated by Toora Women Inc. Consideration has also been given to: the clinical, tertiary level drug treatment service provided by Alcohol and Drug Services Health Directorate; SOLARIS, the therapeutic community (TC) operated by Karralika Programs Inc. and Corrective Services in the Alexander Maconochie Centre; other types of alcohol, tobacco and other drug (ATOD) services that interface with residential drug rehabilitation services; and progress made towards the establishment of an Aboriginal and Torres Strait Islander residential rehabilitation facility (the Ngunnawal Bush Healing Farm) scheduled for completion in June The Review has been completed within the broader context of the ACT Alcohol, Tobacco and Other Drug Strategy The Strategy identifies a range of actions that potentially have relevance to residential rehabilitation services including: improving access to smoking reduction and cessation programs for target populations including people with alcohol and other drug (AOD) problems and workers of ATOD services; implementing national clinical guidelines for the management of drug use during pregnancy, birth and the early years of the newborn; Page 9 of 92

10 ensuring detainees are able to access the same community-based ATOD programs in detention and when they leave detention; developing a consumer participation policy framework to support consumer participation in drug treatment and support services; providing better access to drug counselling, withdrawal, rehabilitation and relapse prevention services in collaboration with mainstream health services by: - AOD treatment and support services working in partnership with a broad range of communitybased primary health care services provided at youth services, Community Health Centres and Walk In Centre/s, and focus on whole person care; - improving access to screening, vaccinations, information and education, counselling and treatment in relation to hepatitis A, B and C and other blood borne viruses, mental health services and sexual health care; - ensuring those on opioid maintenance treatment (OMT) including those who wish to cease OMT over time, and those requiring shorter term programs have access to rehabilitation and other treatment services; and - ensuring drug treatment and support services utilise common screening, assessment and outcome measurement. expanding access to tertiary-level services provided by the Alcohol and Drug Services (ADS) Health Directorate, ACT Government, by - expanding the role of the 10 bed withdrawal unit to include those with other complex AOD problems; - establishing a walk-in outpatient clinic; - increasing participation in community based multi-disciplinary teams with GPs, pharmacists and the relevant non-government AOD services. In addition to the ACT Alcohol, Tobacco and Other Drug Strategy , the Review has been completed within the broader context of the Draft ACT Comorbidity Strategy The Draft ACT Comorbidity Strategy clarifies directions and priorities for those working with people at risk of, or experiencing both mental health problems and alcohol, tobacco and other drug (ATOD) problems. The Health Directorate - ACT Government is currently undertaking a major Health Infrastructure Program. This program includes plans to: establish the Ngunnawal Bush Healing Farm (the ACT s Aboriginal and Torres Strait Islander Drug and Alcohol Rehabilitation Service) catering for clients aged 18 years and over. It is currently in development with an anticipated opening date of June The facility will initially be built with 8 beds, with a masterplan for 16 beds. Its development is overseen by the Ngunnawal Bush Healing Farm Advisory Board, whose membership includes the United Ngunnawal Elders Council, Aboriginal and Torres Strait Islander Elected Body, community controlled organisations, and ACT Government Directorates; Page 10 of 92

11 establish a new Adolescent and Young Adult Mental Health Inpatient Unit, with work currently underway to define the Model of Care for services for 0-25 year olds; open a new Gungahlin Community Health Centre in September 2012; a new sub-acute facility is expected to be built on the north side of Canberra; and open a new Belconnen Community Health Centre in mid Methodology The Review examines evidence for the need for drug and alcohol rehabilitation services in the ACT; international and local evidence of what contributes to good outcomes from drug and alcohol rehabilitation services; data on current drug and alcohol rehabilitation service provision and usage patterns; and consumer feedback on drug and alcohol rehabilitation services in the ACT. Site visits were conducted to residential rehabilitation services in the ACT from December 5-9, 2011 to provide an opportunity for services to discuss their service delivery and planning, and to assess current service provision arrangements and future needs. Mr Ray Lovett, Dr Phyll Dance, Dr Jill Guthrie and Ms Katherine Thurber (researchers based with the Australian Institute of Aboriginal and Torres Strait Islander Studies - AIATSIS and the National Centre for Epidemiology and Population Health - NCEPH) were contracted to undertake community consultations to provide the consumer input to the Review Site visits to residential rehabilitation services and other drug treatment and support services in the ACT by Dr Rod MacQueen and Mr Andrew Biven during the week commencing 5 December Meetings were held with key stakeholders including the Alcohol, Tobacco and Other Drug Association ACT (ATODA), Family and Friends of Drug Law Reform and the following residential rehabilitation services and other drug treatment and support services: DIRECTIONS ACT Althea Clinic and Arcadia House Salvation Army Canberra Recovery Service Alexander Maconochie Centre Hume Health Centre and SOLARIS Ted Noffs Foundation Ngunnawal Bush Healing Farm Advisory Board Meeting Winnunga Nimmityjah Aboriginal Health Service Toora Women Inc Lesley s Place and Marzenna Karralika Programs Inc CatholicCare STEPS Program Alcohol & Drug Service, Health Directorate ACT Government Page 11 of 92

12 Canberra Alliance for Harm Minimisation and Advocacy (CAHMA) In brief, discussions with services centred around the following: How people get in to a service; What happens for residents while in a service; Links with other services/groups; Staffing; and Utilisation. See Appendix 1 for the full list of interview questions Consumer feedback This took the form of 2 focus groups and a consumer survey, and aimed to identify: Consumer treatment service satisfaction/dissatisfaction Treatment satisfaction/dissatisfaction Access barriers Ways to improve Focus group participants were recruited through key informants in the ATOD sector and through current residential treatment services. The two focus groups comprised five and fifteen people respectively. Both focus group sessions lasted about three hours. The survey instrument was developed by the researchers and comprised a sub-set of questions from three validated instruments, namely: ACT Service User Satisfaction Survey (Atkinson & Greenfield, 2004). The questions used were limited to those relevant to the specific focus of this project, i.e., alcohol and other drug rehabilitation services. Treatment Perceptions Questionnaire (Marsden et al., 2000). A validated instrument used to assess treatment satisfaction among people who have been treated for substance use problems. A modified health services access survey from Statistics Canada (Béland 2002). These questions were used to identify issues around gaining access to treatment services in the ACT and also aimed to assess how consumers gain access to residential alcohol and other drug services information in the ACT. Detailed information in relation to the methodology adopted for the consultations and a copy of the survey instrument are provided in Appendices 2 and 3. Page 12 of 92

13 3. Population and epidemiological analyses of the prevalence of alcohol and other drug misuse This section provides contextual information about the overall size and profile of the ACT population. It also provides an analysis of the prevalence of alcohol and other drug misuse to inform the Review in relation to the need for rehabilitation services in the ACT. 3.1 Population of the ACT All statistics reported in this paragraph were sourced from the State and Territory Statistical Indicators produced by the Australian Bureau of Statistics (2011). As at 30 June 2011, the estimated resident population (ERP) of the ACT was approximately 365,400. Overall the ACT has a well educated population with high levels of participation in employment relative to the rest of Australia. In December 2011, the trend unemployment rate in the ACT was 3.8% (the lowest in the nation). The trend estimate of the labour force participation rate was 72.1%, above the national rate of 65.4%. There were 204,900 employed persons; 106,200 employed males and 98,700 females employed. Average weekly full-time ordinary time earnings in the August 2011 quarter in the ACT for males was $1,606.60, a rise of 3.7% from the same time 12 months earlier and for females $1,417.00, an increase of 4.3% over the same period. In 2010, almost three-quarters (74.6%) of people aged years in the ACT had a non-school qualification. This percentage has increased from 63.0% in In 2010, about twothirds (65.8%) of the ACT population aged years were engaged in a full-time or part-time course of study at an educational institution. This compares with 59.1% of the same age group across Australia. The size of the ACT population is projected to increase from about 350,000 persons in 2010 to 404,958 by 2019 (ACT Government, CM&CD, 2011). Across Canberra, an average 1.4%per annum population increase is projected through to The largest areas of growth over are projected to be in Gungahlin-Hall (58.6%) and North Canberra (17.6%), followed by South Canberra (14.9%) and Belconnen (7.3%), with Tuggeranong achieving negative growth over the same period (-1.7%) (ACT Government CMD, 2009). There is a geographical disadvantage for those in the north of Canberra wishing to access drug treatment services as, in terms of the current physical location of drug treatment services across Canberra relative to the distribution of the population, services tend to be concentrated in Civic and in the south of Canberra (unpublished mapping study, ACT Health Directorate, AOD Policy Unit, 2011). In light of this observation, it is important to note that many of the drug treatment and support services have expressed interest in outreaching into existing Government buildings in the north of Canberra such as the Belconnnen and Gunghalin community health centres, to improve access for clients on the north side of Canberra to services. If this occurs, and drug treatment services co-locate in the north, it could provide opportunities for joint delivery of programs such as day rehabilitation programs and could also provide opportunities for people to access services who would not otherwise have travelled to the south of Canberra. The ACT has a fast-growing population that includes those who have high levels of participation in the community, through for example education and employment, but, as identified in the ACT Alcohol, Tobacco and Other Drug Strategy , also has a significant proportion of people in at-risk groups for a variety of alcohol and drug-related harms. In addition, the catchment area for Canberra services often includes a significant stretch of coastal and inland Southern NSW, and services report that a proportion of their clients come from interstate (see section 6 below). Page 13 of 92

14 3.2 The extent and nature of the use of alcohol, tobacco and other drugs (ATOD) in the ACT and the harms associated with that use. McDonald (2012) highlighted published data in his report The extent and nature of alcohol, tobacco and other drug use, and related harms, in the Australian Capital Territory. 1 This report provides a useful picture at a population level of the extent and nature of drug use in the ACT and harms associated with that use. The evidence from McDonald s report is relayed here, with McDonald s permission, and is complemented by information from the ACT Alcohol, Tobacco and Other Drug Strategy which highlights specific target populations at elevated risk of harm caused by their drug use. Taken together, the picture presented suggests that the ACT has: significant levels of risky alcohol consumption in adults, similar to the national rate; lower than national rates of tobacco consumption in the general ACT population but continuing risks and harms in specific population cohorts; continuing risks and harms of illicit drug use, including poly-drug use, in specific population cohorts; a higher than national average rate of hepatitis C infection; and, on the basis of 2007 data, a higher than national average mortality rate from opioid overdose. Alcohol McDonald notes that of the 86% of ACT adults that state that they use alcohol, 20% report drinking at a risky level of consumption as defined by the National Health and Medical Research Council (AIHW 2011a). Specific target populations identified in the ACT Alcohol, Tobacco and Other Drug Strategy to be at elevated risk of harm caused by their alcohol use include: People who use other drugs as well as alcohol (e.g illicit drugs such cannabis and heroin) People in detention People with mental illness Aboriginal and Torres Strait Islander peoples Indicating the high risk of risky alcohol consumption and poly-drug use in the ACT prison inmate population, the 2010 ACT Inmate Health Survey Summary Results provides data on prison inmate health in the ACT (ACT Government 2011). Respondents to the survey reported that, in regard to their alcohol and other drug use: 33% consume 6 or more drinks on one occasion daily or almost daily 16% have consumed alcohol while in prison 24% were dependent on alcohol 49% were dependent on a drug other than alcohol. 1 McDonald, D. (2012) The extent and nature of alcohol, tobacco and other drug use, and related harms, in the Australian Capital Territory, 4 th edition, ACT Government Health Directorate. All references to McDonald in this section are to this edition. Page 14 of 92

15 Tobacco McDonald notes that the ACT s prevalence of daily tobacco smoking, 11%, is well below the national prevalence. However, smoking rates remain high within the ACT amongst specific populations identified in the ACT Alcohol, Tobacco and Other Drug Strategy including: People who use alcohol and other drugs People in detention People with mental illness Aboriginal and Torres Strait Islander people Women with low to middle incomes Men with low to middle incomes Substantiating the higher risks to those in detention, respondents to the 2010 ACT Inmate Health Survey (ACT Government 2011) reported that, in regard to their tobacco use: 85% were current smokers 32% have more than 20 smokes per day. Illicit Drug Use McDonald notes that cannabis is the illicit drug most frequently consumed in the ACT, with 10% of household survey respondents aged 14 years or older reporting recent use. The next most commonly consumed drug category is the use of opioid analgesics for non-medical purposes (2.9%). Polydrug use is the norm among people who inject illegal drugs and ecstasy -related drug users. Heroin, MDMA ( ecstasy ), cannabis, methamphetamine and cocaine are said by users to be easy to very easy to obtain in the ACT (Arora & Burns 2011; Spicer, Arora & Burns, 2011). Use of illicit drugs within the ACT is higher amongst specific populations identified in the ACT Alcohol, Tobacco and Other Drug Strategy including: People who use alcohol and other drugs People in detention People with mental illness Aboriginal and Torres Strait Islander people Indicating the higher risks of illicit drug use experienced by the ACT prison-inmate population, the 2010 ACT Inmate Health Survey Summary Results provides data on prison inmate health in the ACT (ACT Government 2011). Respondents to the survey reported that, in regard to their illicit drug use: 91% have ever used illicit drugs 67% have ever injected drugs Page 15 of 92

16 Overdose is a major health threat to people who consume drugs. Referring to ACT Ambulance data and his own calculations, McDonald notes that the ACT Ambulance Service attended 601 overdose incidents in the first 10 months of 2011, of which 42% were from alcohol, 22% from polypharmacy, and 10% from heroin. Pharmaceutical drugs accounted for most of the remainder. Following Roxburgh & Burns, McDonald notes that the ACT mortality rate from opioids, 1.7 per 100,000 aged years (six deaths), was 30% higher than the national rate in 2007, the most recent year for which ACT data are available (Roxburgh & Burns 2011). While McDonald concludes that on most indicators the prevalence of harms related to psychoactive substances in the ACT are stable or falling,.. the increasing levels of consumption of pharmaceutical opioids (both prescribed and diverted from licit sources) and harms related thereto, seen nationally, is probably occurring in the ACT, though is as yet largely undocumented. In addition, the ACT is probably experiencing an increase in the availability and use of potentially-harmful synthetic cannabinoids (formerly known as legal highs ). Of particular concern, in 2010, 223 cases of hepatitis C infection were diagnosed in the ACT, a rate 17% higher than the national level. The ACT rate fell markedly from 1995 to 2009, but has moved to a higher level in the subsequent two years (Kirby Institute 2011). Criminal activity while using alcohol and other drugs There are significant numbers of ACT residents report engaging in dangerous or otherwise problematic activities while under the influence of alcohol and/or other drugs. Drawing on Australian Crime Commission data, McDonald reports that this includes 18% driving a motor vehicle while under the influence of alcohol and 6% going to work in that condition. 23% of people who had used illicit drugs in the year before interview reported driving under the influence of drugs other than alcohol, with 13% going to work in that condition (Australian Crime Commission, 2011). McDonald reports that in the year, a total of 459 arrests or Simple Cannabis Offence Notices (SCONs) for all drug offences were made in the ACT and that this represents a rate just 34% of the equivalent national rate. He notes that cannabis consumers (i.e. offenders not classified as providers) composed 64% of all ACT drug arrests plus SCONs in that year, compared with 57% nationally. At 30 September 2011 just 3 of the 171 inmates of the Alexander Maconochie Centre (AMC; Canberra s prison) had a drug offence as the most serious offence for which they were incarcerated. Three-quarters (74%) reported that the crimes for which they were imprisoned were drug-related (ACT Government JACSD 2011). According to the ACT Government s 2010 ACT Inmate Health Survey Summary Results, 79% of respondents were under the influence of alcohol/other drugs at time of committing the offence that led to their imprisonment (ACT Government 2011). Some 32% reported injecting illegal drugs while at the AMC and 27% reported that the last time they had injected was in a prison (Stoové & Kirwan, 2011). 3.3 Observations on population and epidemiological data On the basis of projections that indicate population increases in the ACT, particularly in the north of Canberra, better drug and alcohol treatment service provision is needed for those living in the north of Canberra. This may be provided through outreach models rather than the replication of existing services. Page 16 of 92

17 In addressing specific needs and harms, the ACT evidence suggests that treatment services better targeting those with problematic: alcohol use; cannabis use; polydrug use; and opioid use are all needed, and that strengthened primary care interventions to deal with concerning rates of Hepatitis C infection are needed. A particular sub-population of need in limiting Hepatitis C infection are those in prison, given rates of reported injecting drug use while in prison. Page 17 of 92

18 4. Review of the International and Local Evidence Relating to Outcomes in the Drug Rehabilitation Area This section provides a selected account of the international and local evidence relating to outcomes in drug and alcohol rehabilitation services. This information informs the review at the level of identifying the known indicators for improved outcomes and, building on this evidence, what is best practice in the field, both in terms of implementation of treatment processes and selection of treatment types. 4.1 What is drug and alcohol rehabilitation? In Australia, the Alcohol and Other Drug Treatment Services (AODTS) National Minimum Data Set (NMDS) Specifications and Collection Manual provides a means of collecting standardised national data about clients accessing alcohol and other drug treatments and services which can inform policy and debate in the alcohol and other drug treatment sector. The manual defines rehabilitation as: An intensive treatment program that integrates a range of services and therapeutic activities that may include counselling, behavioural treatment approaches, recreational activities, social and community living skills, group work and relapse prevention. Rehabilitation treatment can provide a high level of support (i.e. up to 24 hrs a day) and tends towards a medium to longer-term duration. Rehabilitation activities can occur in residential or nonresidential settings. (AIHW 2010, p. 66) This definition provides some useful parameters for this paper: rehabilitation is an intensive treatment program that can be multi-faceted. It can occur in either residential or in non-residential settings and tends to involve medium to longer-term (rather than short-term) interventions. This list is indicative rather than exhaustive, and the literature suggests that rehabilitation programs can be adapted to accommodate shorter treatment lengths and different cohorts of clients. There is an increasing trend, too, towards offering OMT as an integrated part of residential rehabilitation programs, where in the past these have been predominantly abstinence-based (Magor-Blatch 2011). Drawing on the AODTS NMDS definition, the literature reviewed is primarily that on intensive, medium to longterm treatment interventions that can be provided as a residential or a non-residential service and can consist of a variety of treatment elements. These interventions include: opioid maintenance therapy, outpatient programs, and residential rehabilitation programs including but not limited to therapeutic communities. 4.2 What are desired outcomes of drug and alcohol rehabilitation? The Australasian Therapeutic Community Association (ATCA) following two reports to the Victorian Government in 1994 and 2000, refers to outcomes as measurable changes in a client s quality of life as a result of treatment interventions, defined as either an increase in desirable characteristics or a decrease in an undesirable condition (ATCA 2002, p. 15.), and cites the following five outcomes of effective treatment from the Victorian work: Reduced substance abuse Reduced high risk behaviour Improved physical health Improved social functioning Page 18 of 92 Improved emotional and psychological well-being

19 (ATCA 2002, p. 16) Studies measuring longitudinal outcomes for drug and alcohol treatment include: in Australia, the Australian Treatment Outcome Study (ATOS); in North America, the Drug Abuse Treatment Outcome Studies (DATOS); and in the United Kingdom, the National Treatment outcome Research Study (NTORS). Each of these studies interrogates indicators of treatment efficacy over time, post treatment, based on some or all of the criteria listed above: changes in substance use; rates of illegal activity; rates of employment; changes in psychological health; rates of behaviours associated with health problems, eg. needle sharing (Gossop et al. 2003; Hubbard et. al. 2003; and Teesson et al. 2007). The studies consider a range of treatment types ranging from opioid maintenance therapy programs run in community settings through to specialised drug dependence units run in hospital settings. All three studies conclude that a number of improved outcomes after drug abuse interventions are still evident three or five years after treatment. With reference to the criterion improved emotional and psychological well-being, recent consumer-focused research on quality of life of those in drug treatment has raised awareness of the need for treatments and for outcomes measures to take a broader, more holistic, approach. The desire for improved satisfaction with life is a desired outcome and a common driver of seeking drug treatment (De Maeyer et al. 2010; De Maeyer et al. 2011; Magor-Blatch 2011). In addition to measuring health benefits and reduction in substance abuse, it is important also to recognise social inclusion and self-determination, factors associated with improved quality of life, as desired goals of drug and alcohol rehabilitation. A new definition of recovery from mental and substance use disorders that was developed by the Substance Abuse and Mental Health Services Administration in the United States in 2011 defines recovery as a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential (SAMSHA 2011). This definition captures autonomy and quality of life as pivotal outcomes. 4.3 Factors associated with improved outcomes Factors that are considered to contribute to long-term positive effects include: Length of stay in therapy Matching treatment to client Relationship between client and therapist (McDermott, Hamilton & Lagay 1991, pp ) Extended interventions, across a range of treatment types: pharmacotherapy, behavioural therapy and monitoring, and across varied modes of delivery: face-to-face or telephone delivery, residential and day programs, have been associated with improved outcomes (McKay 2005; De Leon et al. 1995). Building on these sorts of findings are strategies that maximise retention rates. In therapeutic communities, for instance, preparation for treatment and offering additional services to target specific needs have been identified as having the potential to improve retention rates (ATCA 2002, p. 30). In addition to extended treatment, more stable maintenance in a therapy (Teesson et al. 2007, p. 87; Darke et al. 2012) and greater participation or intensity of treatment (Hser 2004 et al.; Schulte 2011 et al.) are also associated with positive outcomes. Completion of a treatment program, as opposed to mere length of stay, is another indicator associated with better outcomes (Magor-Blatch 2011). A study on retention, dropout rates and completions among those admitted to an Australian therapeutic community (TC) suggested that a previous successful completion of a TC program is associated with higher likelihood of retention and completion (Darke et al. 2012). Individuals Page 19 of 92

20 voluntary engagement in activities that tend to reinforce and complement formal treatment elements, such as attending social events and socialising with others in rehabilitation, may also contribute to improved outcomes (Zemore & Kaskutas 2008). Availability of treatments that coincide with client preferences (eg. availability of harm reduction initiatives versus abstinence-only options) can affect the numbers engaging in treatment in the first place. This may be affected by geographic location, particularly in rural areas. Research looking at treatment choice and its affect on outcomes finds an association between treatment preference and choosing to engage in treatment at all (Peavy et al. 2010). Matching program intensity to client need is increasingly reflected in the literature. The 2011 British Columbian Standards for Residential Substance Use Services (BCMoH 2011) describe a five-tier service model with Tier 5 being the most intense level, involving specialist, residential, service provision and Tier 1 involving self-care, family support, and school-based prevention. The standards make the point that treatment level needs to be matched to the acuity, chronicity and complexity of the client s needs (p. 6) and that most of those needing help would find it in non-residential, community-based services but that some with more complex needs will benefit from being addressed in more structured and intense service provided from residential rehabilitation settings (p. 5). There is some evidence that non-residential structured day programs with elements of a therapeutic community incorporated are at least as effective as residential programs for certain clients. (De Leon ed. 1997, Greenwood et al 2001). There are existing examples of day rehabilitation programs based on a variation of the Therapeutic Community model that are running in Australia (Gold Coast Drug Council Inc. 2011). An argument has also been made that outcome measures ought to reflect thinking about addiction as a chronic condition, that is to say, that effective drug rehabilitation treatment, like treatment for chronic disease, is effective so long as it continues to be administered (McLellan 2002, p. 249). The implications here for good practice and for measuring good outcomes in drug rehabilitation are that treatment is not something confined to a limited period of time that effective drug rehabilitation is an ongoing process and commitment for both treatment providers, for whom it needs to be about continuity of treatment, and for clients, for whom it needs to be about changing behaviour over a long period of time (Sellman 2009). 4.4 Good practice in service delivery In late 2009, the Intergovernmental Committee on Drugs (IGCD) endorsed the development of a national population based planning tool for drug and alcohol services across Australia. The project is due to be completed in late The purpose of the model is to provide a consistent and transparent basis for all jurisdictions to estimate gaps between current services and what is required. A key component of the model is the development of care packages according to the age of people, whether they have a mild, moderate or severe drug problem and the nature of the drug they have the problem/s with. Core elements of those packages are likely to include: Prevention and Harm Reduction Interventions Psychosocial Interventions Medication Withdrawal Management Residential and Non-residential Rehabilitation Page 20 of 92

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