Prison Based Drug & Alcohol Recovery Pathways

Transcription

1 Prison Based Drug & Alcohol Recovery Pathways

2 01 02 Contents What we mean by Recovery Focussed Services Assessment and Case Management Healthcare and Clinical Services Motivating Change Structured Programmes Release and Reintegration Glossary of Terms Page 03 Page 05 Page 07 Page 09 Page 11 Page 13 Page 15 From 2013 onwards, RAPt has been awarded contracts to provide substance misuse services in 27 prisons, with responsibility for integrating all aspects of drug and alcohol treatment interventions. Our approach promotes recovery from addiction through a seamless service, covering healthcare and psychosocial interventions from reception right through to transfer or release from prison. Our new operating model allows the clinical and psychosocial teams to work closely together to integrate all of these interventions efficiently. This booklet describes the various components of this integrated model, and how they work together in support of the prisoners recovery journey.

3 03 04 What we mean by Recovery Focussed Services RAPt was founded on the belief that all people can achieve recovery and can attain and sustain productive lives. This is equally true of people who are in prison. This belief is backed up by over two decades of work with prisoners, where people with serious, long-term and entrenched drug use, linked to criminal behaviour, and with other complex needs, have entirely turned their lives around with the support of their peers, and also RAPt staff and volunteers. Our treatment programmes, working with some of the most complex and high needs prisoners in the system, have achieved a one-year reduction in the volume of post release offending of 65%, compared to the offending rates of people with identical needs who did not engage with our programme. Our new service models aim to bring that promise of recovery to everyone in the system, not just those who are lucky enough to be offered a place on an intensive treatment programme. Achieving this requires linking up our services in prisons with services in other prisons and support in the community. We have learnt that quality professional support, in tandem with clear recovery stepping stones, and peer role-models/mentors, delivers results with people who are often written off. RAPt recovery focussed services are of course founded on an evidence-based approach, underpinned by a knowledge of what works, adapted to each prison and the systems of the different communities and areas which work with that prison. Our approaches are codified into a comprehensive set of manuals. They are also accredited by the CSAP (Correctional Services Accreditation Panel), and supported by training, a culture of learning and good management practices. However, it isn t just about systems, it is about belief in the client; instilling that belief in them too, and in all the people around the client - be that other services or friends and family. Our approach involves listening to the client, accepting them for who they are, and working with them in a person-centred way to develop insight, aspiration, opportunities and positive actions which benefit the client, the establishment, the family and the wider community. Everyone in our services nurses, doctors, psychosocial practitioners, volunteers, and peer supporters are expected to instil that recovery ambition in the people they work with.

4 05 06 Assessment and Case Management Assessment Every client receives a comprehensive needs assessment. Our assessments use evidence-based tools to ascertain levels of substance dependency (and therefore what treatment options are most appropriate) but also cover physical health, mental health, housing needs, family involvement, personal and life skills, work, education and training. The approach taken is motivational in style and seeks to focus on individual strengths and recovery capital; this is achieved through a strengths-based recovery planning approach. Our assessment processes are co-ordinated, including with other providers, so that clients are not subject to unnecessary duplication of assessment. Node - Link Mapping Our case managers have used node-link mapping for some time; we therefore welcomed the adoption of this in prisons. We have found that this approach works well during the process of recovery planning, and that service users welcome a collaborative approach that encourages them to set treatment goals which are dependent on choice and need. Assessment and node-link mapping provides information which the client and care co-ordinator examine together to make choices and agree a care plan. The role of the care co-ordinator Each client has a named care co-ordinator who brokers a package of appropriate support from the beginning to the end of their sentence, with particular attention to the period of entry into treatment. The care co-ordinator also has a specific focus on the period leading up to release/transfer and takes a primary role in facilitating an effective handover on release and follow through into other prisons and the community. Practitioners build rapport and use their professional knowledge and skills to expedite the client s use of services along a care pathway that is individually tailored to their needs. Provision of harm reduction advice and services Harm reduction and overdose prevention are core, and are embedded into all interventions. Our aim is to equip people with the necessary information and sources of support to stay safe and minimise health risks. This is prioritised in the early stages of engagement and prior to release. Staff deliver information and advice through one-to-one sessions, RAPt Living Safely workshops, and during screening and assessments. In cell information packs are distributed to all new receptions. Information is widely available on a range of harm reduction and public health topics e.g. risks, BBVs (blood borne viruses), substitute prescribing, ensuring personal safety, alcohol, prescription drugs, legal highs, smoking cessation, diet, health and wellbeing. Data collection and review We use systems of data collection which work with and support prison systems (including SystmOne and NDTMS, and the roll-out of DET). Data is used to analyse care pathways, to ensure that what is available is being accessed in the right way and is effective in meeting needs and client choices. We hold a unique database on all of our clients, analysis of which is used to inform our programme of continuous clinical improvement, and also for independent research into outcomes. Care plans are reviewed on a regular basis, as any recovery journey is characterised by change, the need for additional or different support, and sometimes set-backs which need to be responded to.

5 07 08 Healthcare and Clinical Services The Clinical Pathway The safe and professional management of the medical and healthcare needs of our clients is of crucial importance to us. Where we provide clinical services directly, or where we work with partners, our aim is to ensure clinical delivery with an emphasis on quality, safety and efficiency. New Receptions A clinic, led by a substance misuse nurse, takes place every morning for new clients with alcohol and substance misuse problems. Clinical staff ensure that prisoners who require clinical treatment are immediately assessed and that treatment is available to prevent or manage withdrawal symptoms and risks. Prisoners are screened for viral hepatitis, HIV, infectious and other diseases (including TB) as well as dental disease. Substitute opioid prescribing (for stabilisation or detoxification), treatment for benzodiazepine dependency, support for stimulant withdrawal, alcohol detoxification and all other clinical interventions follow NICE guidance and best practice protocols. Day Five Review Clinics Five day reviews are carried out on everyone who has commenced opioid substitution treatment. Review and Prescriptions Clinics The timing of these reviews will depend on the stage the client has reached in their treatment journey, with complex cases and those undergoing changes in dose seen more regularly. RAPt staff and peer supporters encourage reduction and abstinence, though it is recognised that this may not be possible for people on remand or those serving very short sentences. However, the aim is always to motivate and encourage people to move towards abstinence. Information about fellowship meetings in the community is provided. 13 Week Review Clinics Every patient who remains on methadone for more than three months undertakes a 13 week review. Care plans are reviewed, often with other stakeholders involved in the care of the client, such as mental health in-reach or the Offender Management Unit (OMU). A key aspect of these clinics is to gauge patient readiness for abstinence and to put in place a care plan which will support clients to achieve this. Complex Cases We work closely with the mental health/in-reach teams to ensure that patients with dual diagnosis are appropriately managed in a coherent and joined-up manner. Naltrexone The option of naltrexone is available where requested and clinically indicated. Naltrexone may be prescribed following detoxification to those who require assistance to sustain abstinence from opioids and where the relevant support in the community is available on release. Continuity of Treatment All patients attending courts or leaving prison with ongoing prescribing needs are given FP10s and discharge summaries to take to their GP if they are released directly from court. Discharge plans are sent to GP's and other community agencies to maintain continuity and quality of care.

6 09 10 Motivating Change Our entire service is about creating the conditions and motivation for people to believe that they can make positive and lasting changes in their lives, and to get up and do something about it. These can be changes such as reducing or ceasing drug or alcohol use, but can also be about changing the way they treat family members, or working towards a job. Our services include the following interventions to further aid the building of motivation: Motivational Enhancement Therapy (MET) Studies have found that use of an MET approach is crucial for empowering service users to take ownership of their recovery. Loss of motivation and hope for change are strongly associated with treatment attrition and are the most frequently reported reasons for dropping out of or not engaging with treatment (Ball et al., 2006; Broome et al., 2002). MET is one of the most carefully developed and rigorously studied brief therapeutic interventions (Miller and Rollnick, 1991; Ball et al., 2006). Even in brief treatment doses, MET has been shown to significantly increase motivation and self-efficacy (Claus and Kindleberger, 2002). MET interventions have been shown to work well as primers before engagement in more intensive treatment, such as 12-Step. Seeking Safety Seeking Safety is a form of cognitive behavioural therapy (CBT) incorporated as therapeutic skills training sessions in RAPt s programmes. It recognises the importance of the symptoms of trauma on substance misuse, and provides integrated treatment to manage the symptoms of both. Seeking Safety focusses on practicing safe coping skills that are essential for recovery, such as asking for help, setting healthy boundaries, managing anger and relaxation. Various studies have demonstrated that such an integrated approach for substance misuse and trauma is more effective than treatments addressing just one or both sequentially, as recommended in the NICE guidelines (2007). Seeking Safety has also been shown to be compatible with the 12-Step approach. Peer Support Support from peers is offered to all clients. We have pioneered the use of peer supporters in prisons, and have a network of hundreds of prisoners willing to offer their advice and guidance to others in earlier stages of recovery. Peer supporters will: Attend induction groups and describe the treatment services Provide out of hours and weekend support Co-facilitate all groupwork sessions including those on structured programmes Work closely with service users whose goals include clinical treatment Facilitate evening and weekend Mutual Aid Groups; including NA/AA and SMART Recovery Deliver a specific peer-led intervention, PLUS (Peer-led User Support). We have developed this service with our clients to help people make the transition from substitute prescribing to abstinence treatment Living Safely Living Safely is a menu of workshops offered to all clients engaging with RAPt integrated services. These workshops are aimed at minimising drug and alcohol-related harm, and providing safe coping and emotional management skills, thereby empowering clients to build healthier lives and relationships. This intervention is designed to be run in response to client needs, with relevant workshops selected from the menu of 25 topics provided. The topics include educational workshops on the danger of using and mixing specific substances, safer injecting, overdose prevention and binge drinking. They also include therapeutic and motivational workshops that focus on holistic lifestyle changes, such as setting healthy boundaries in relationships, self-care, assertiveness, healing from anger and getting others to support your recovery. Relapse Prevention Planning workshops are regularly delivered for clients who are nearing release. For some clients, Living Safely workshops may be the only intervention that they engage with, particularly if they are nearing release. These workshops therefore play an essential role in motivating clients to engage with further support and providing them with skills to maintain their own safety. For many clients, particularly those who are using drugs or alcohol at harmful or dependent levels, Living Safely is designed to act as a pathway into one of RAPt s structured programmes, such as Stepping Stones, SDTP, Bridge or ADTP. Stepping Stones This is a medium intensity, part-time, rolling four week, 20-session programme. It is designed to meet the needs of offenders who misuse drugs and/or alcohol and who are serving short sentences or are on remand. The programme is inclusive of participants who are using methadone. Stepping Stones is not strictly abstinence based but encourages participants to view this as the safest goal. The programme comprises four core modules focussed on learning and practising coping skills to stay safe. It also covers ways to manage triggers, cravings and symptoms of anxiety and trauma, which if left unaddressed, would be likely to undermine recovery. Participants may join the programme during any module/topic (once they have attended their one-to-one intake and orientation session). Positive role modelling is a strong aspect of this programme, with peer supporters running groups during out of programme hours, as well as providing support in sessions.

7 11 12 Structured Programmes RAPt s experience and research shows that people who are dependent on drugs or alcohol require structured and intensive treatment to achieve long term behaviour change. That is why we have developed a range of structured treatment programmes for the different needs of both men and women. We have the largest range of accredited structured and intensive treatment programmes in the prison system. Substance Dependence Treatment Programme (SDTP) Alcohol Dependence Treatment Programme (ADTP) This programme is the same as the Bridge programme in terms of duration, intensity and treatment methods. The only difference is that it is aimed at offenders with a history of alcohol dependence, and therefore specific skills, training topics and use of AA literature are included to meet the distinct needs of this client group. This is the only accredited intensive programme for alcohol-dependent clients available in the prison system. This is an intensive, full-time, week, abstinence-based 12-Step offender behaviour programme. It is aimed at medium-high risk offenders with a history of drug dependence, and is ideally intended to be run on dedicated residential units. It takes people through the first five of the 12-Steps of AA/NA and includes group therapy, step reading groups, community meetings, speaker meetings/video sessions, assignment sessions, educational sessions, peer evaluations, goals groups, graduations, significant events sheets, meditation and wind downs, and fortnightly one-to-one counselling sessions. Every client will also develop a focussed relapse prevention plan. Women s Substance Dependence Treatment Programme (WSDTP) The Women s version of the SDTP is the same in length, structure and intensity as the men s programme. Topics/workshops have been incorporated into the programme on the basis that they have been shown to be most relevant and effective for this client group. In addition, there are more workshops on healthy relationships, and family conferences are offered to all programme participants. Bridge Programme This is an intensive full-time, six-week, abstinence-based, 12-Step offending behaviour programme aimed at medium-high risk male offenders with a history of drug dependence. The programme s length enables prisoners with shorter sentences to access intensive psychosocial treatment. This provides them with an opportunity to acquire fundamental relapse prevention skills and to develop pro-social, drug-free social support. The programme is entitled the Bridge Programme because it engages participants, provides them with basic coping skills and actively links them to further post-release treatment and support.

8 13 14 Release and reintegration RAPt was founded on the principle that prisoners can be helped to stop using drugs and/or alcohol, and can achieve and sustain productive lives. We have always measured how we impact on people s lives, whether people go on to re-offend, and what they go on to do after they leave our treatment programmes and prison. That is why we are able, with confidence, to claim that our service models will deliver recovery and resettlement outcomes. But we also recognise that the period around release from prison is a high risk one, and many of our clients will return to drug use, with all the associated risks. We therefore include in our release planning work a specific focus on the delivery of harm reduction advice and practical support, with the aim of reducing the risk of overdose and other health problems that can arise from a return to drug use. Release planning We recognise that substance misuse services represent just one group of several pathways for all prisoners, which also include: - Accommodation - Education, Training and Employment (ETE) - Mental and physical health - Finance, benefits and debt - Children and families Every prisoner will have a care plan which attends to each of these areas. In addition, every person who leaves prison will have a fully developed relapse prevention plan and will have received tailored harm minimisation advice directly before leaving the establishment. Recovery support We try our hardest to ensure that continuity of treatment and care is provided. This includes joint working with community agencies and follow-up to ensure that engagement is happening. However, the main source of support on release is often through informal channels, particularly the support of families and peers. In many of our services, we are able to engage with the families of prisoners to try to create relationships and support which will nurture a person s recovery on release. We encourage prisoners to engage with mutual aid and peer support in the prison and in the community, so that there is always someone on the end of the phone or able to meet for coffee. We offer meet and greet, where a trained volunteer will meet a person on release and take them to their first appointment, or just have a chat. RAPt also provides a national aftercare service. This offers advice and information on all aspects of recovery, including direct support in finding ongoing treatment and housing, and workshops on education, training and employment. We also keep a database of over 3,000 people in recovery, which is networked through a user magazine and regular reunion events.

9 15 16 Glossary of Terms AA (Alcoholics Anonymous): AA is a fellowship of men and women who share their experience, strength and hope with each other that they may solve their common problem and help others to recover from alcoholism. BBVs (Blood Borne Viruses): Blood-borne viruses are viruses that some people carry in their blood and can be spread from one person to another. Benzodiazepine: Benzodiazepines are the most commonly prescribed minor tranquillisers, known as anxiolytics (for daytime anxiety relief) and hypnotics (to promote sleep). Clinical: Clinical refers to medically assisted interventions provided by a nurse/doctor, such as prescribing and detoxification, whose aim is to improve physical and psychological functioning, to improve quality of life and support recovery. CBT (Cognitive Behavioural Therapy): CBT is a talking therapy that can help an individual manage their problems by changing the way they think and behave. CBT deals with current problems, rather than focussing on issues from the past. DET (Data Entry Tool): The Data Entry Tool is a web-based tool that allows drug and alcohol treatment agencies (service providers) to capture essential client information and then to extract this in a file format and submit it to National Drug Treatment Monitoring System (NDTMS) regional offices. Dual diagnosis: Dual diagnosis is the term used to describe individuals suffering from both a mental illness and a substance misuse problem. FP10s: An FP10 is a form used to issue prescription medication in the UK. Harm reduction: In their broadest sense, harm reduction policies, programmes, services and actions work to reduce the health, social and economic harms to individuals, communities and society that are associated with the use of drugs (United Kingdom Harm Reduction Alliance). MET (Motivational Enhancement Therapy): MET is a counselling approach that facilitates behaviour change by helping clients to explore and resolve their ambivalence about making such change and by increasing their self-efficacy. Mutual Aid: Mutual aid can be described as a group of people with similar experiences helping each other to manage or overcome issues, thereby creating a support network. Mutual aid groups come in different types, for example Alcoholics Anonymous and SMART Recovery. NA (Narcotics Anonymous): NA is a non-profit fellowship or society of men and women for whom drugs had become a major problem. It follows a similar structure and the basic principles of Alcoholics Anonymous. Naltrexone: Naltrexone is an opioid antagonist primarily used in the management of alcohol and opioid dependence. Naltrexone reduces the craving for alcohol and can block the effects of drugs such as heroin and cocaine in the brain. NICE Guidelines: Are recommendations by the National Institute for Health and Care Excellence (NICE) on the appropriate treatment and care of people with specific diseases and conditions within the NHS. NDTMS: The National Drug Treatment Monitoring System (NDTMS) collects, collates and analyses information from and for those involved in the drug treatment sector. It is a development of the Regional Drug Misuse Databases (RDMDs), which have been in place since the late 1980s. Node-Link Mapping: Node-link mapping is a simple technique for presenting verbal information in the form of a diagram. Evidence shows that this method is effective for enhancing understanding, memory and treatment engagement. Evaluations show node-link maps are more easily recalled and understood than traditional spoken or written language explanations. Opioids: Opioids are substances which are refined from an extract obtained from opium poppies. Some are produced by chemical synthesis. They include the drugs methadone, morphine, pethidine, codeine, heroin and opium. Psychosocial: Refers to talking interventions provided by a keyworker/counsellor, such as relapse prevention and motivational enhancement, whose aim is to improve personal and social functioning to improve quality of life and support recovery. It can be delivered in either a group or one-to-one environment. Recovery Capital: Recovery Capital refers to the breadth and depth of internal and external resources that can be drawn upon to initiate and sustain recovery from substance misuse (Granfield and Cloud, 2001). SystmOne: SystmOne is a centralised clinical computer system that provides healthcare professionals with a complete management system, including electronic patient records. It provides a single source of information, detailing a patient s contact with the health service across a lifetime. This record should be accessible whatever the care setting (including prison, hospital, community, mental health and social care) and available so any health professional can enter information. It should document every appointment, every medication and every contact the patient has ever had. SMART Recovery: SMART Recovery (Self Management and Recovery Training) is an international non-profit organisation. Its purpose is to support individuals who have chosen to abstain, or are considering abstinence from addictive behaviours, by teaching how to change self-defeating thinking, emotions and actions, and to work towards long-term satisfaction and quality of life. Substitute prescribing: Substitute prescribing refers to prescribing a safer alternative to the problem or drug, e.g. prescribed methadone or buprenorphine instead of street heroin. Using a prescribed substitute is usually only available for problems with opiates, and as just one of the stages of treatment. Substitution treatment is also used in some carefully selected individuals who have problems with tranquillisers (like diazepam or Valium). TB (Tuberculosis): TB is a bacterial infection spread through inhaling tiny droplets from the coughs or sneezes of an infected person. It is a serious condition but can be cured with proper treatment.