IMPROVING DRUG & ALCOHOL RECOVERY OUTCOMES IN OXFORDSHIRE

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1 IMPROVING DRUG & ALCOHOL RECOVERY OUTCOMES IN OXFORDSHIRE REPORT Version Date Author/s Status Kevin Driscoll, Arthur Davis (Data) & Sarah Young (Focus Groups) 2 nd draft with OCC comments added

2 Section Contents Page 1 Background 2 2 Project Approach 3 3 Improving Data Quality & Reporting 5 4 Service User Survey 9 5 Oxfordshire Drug & Alcohol Clinical Practice Event 19 6 Focus Groups 22 7 Conclusion 30 8 Next Steps 31 9 List of Recommendations References Appendices A Action Plan Template 35 1

3 1. BACKGROUND Improving Recovery rates and outcomes for those engaged in treatment has been a key feature of drug and alcohol systems since the launch of the 2010 Drug Strategy. Local Authorities have been provided with a range of Public Health Outcomes indicators and requested to focus on drug and alcohol outcomes as a way of improving the recovery rates and overall health of their local substance misusing populations. In early 2012, Oxfordshire became one of a number of pilot sites around the country to adopt a payment by results (PbR) methodology and the County has been testing this new approach to service delivery since that time Oxfordshire has a large drug and alcohol treatment system with approximately 2,500 people accessing treatment at any one time and for this group treatment provides the platform from which to start recovery and to remain stable and drug free. Nonetheless, Oxfordshire data has shown a reduction in the number of cases of drug users successfully completing treatment drug free and / or free from drugs of dependency and as a consequence PHE has offered to work with Oxfordshire County Council (OCC) to identify and correct data inaccuracies and facilitate a collaborative approach to improve successful completions. This report is the product of that collaborative work 2

4 2. PROJECT APPROACH PHE utilized a project management approach and this consisted of several work-streams that have run either concurrently or consecutively and included the following. Developing Strategic Leadership for Successful Completions Project Work In the first phase of the Project Work, agreement was reached with Oxfordshire County Council at the end of November 2013 on the scope and remit of the work. A full project management approach was then initiated in December 2013 with a timetable and subsequent project plan drawn up to guide the various work-streams of the project. Project Team & Membership Membership of Project Team was agreed in late November 2013 with the Team made up of a range of stakeholders including PHE (chair of Group), Commissioners, Service Providers, Data Managers and Service Users. To date, the Project Team have met on four separate occasions to manage content of work and to agree the next stages of project. The next meeting of Project Team will be held on 9 th April 2014 where full consideration will be given to this Report and its subsequent recommendations. Interrogation of local data As a starting point for the project, an interrogation of available data was undertaken in order to understand where issues were most prominent. The results from the initial data interrogation exercise were considered at the initial meeting of Project Group on 29 th November 2013 and several areas of focus were identified including: Sizeable 6yr+ population Significant client attrition rate at all points of the treatment process Poor outcomes at the 6 month point of treatment especially in terms of non-abstinence and persistent associated misuse of crack and alcohol Sizable treatment population within shared care (approximately 750 patients) with very poor successful completion rates Data quality issues Improving Data Quality & Reporting Data inconsistences and data compliance issues relating to the failed LASARS provider were highlighted fairly early on in the project and as a way of correcting some of these issues the OCC Data Manager was tasked with working with the local PHE Knowledge & Intelligence Team to identify and resolve residual inconsistences with data (this is picked up in Section 3 below). Service User Survey The Service User Survey was initiated over the course of 4 weeks between late December 2013 and Mid-January 2014 with a sample of 106 service users taking part. The Survey findings are contained in Section 4 of this Report. 3

5 Oxfordshire Drug & Alcohol Clinical Practice event As a way of improving recovery rates for those clients involved in Opioid Substitution Therapy (OST) a Clinical Practice Event was held at the Kings Centre, Osney in Oxford on Wednesday 5th March An overview of the findings from this event together with a set of recommendations can be found in Section 5 below. Focus Groups Exploring the theme of recovery with a wide range of stakeholder groups was seen as an important part of the work in Oxfordshire and thus three separate Focus Group exercises were undertaken with Carers & Families, Drug & Alcohol frontline Practitioners and an external stakeholder group (made up of those that work on the periphery of Oxfordshire s treatment system e.g. Police, Probation, Homelessness charities etc). A full Report into the Focus Group exercise is available from OCC but an outline of the key issues raised together with a proposed set of recommendations can be found in Section 6 below. 4

6 3. IMPROVING DATA QUALITY & REPORTING 1 The data issues cut across the following areas: Psychosocial Interventions LASARS episodes open alongside Recovery Service Episodes Poor completion of Start TOPs Creation of local reports Non-Opiate Clients Alcohol Successful Completions Transfers System Training Psychosocial Interventions As part of the work toward improving successful completions, the types and numbers of interventions offered at each service were analysed from OTIS data. From this it was found that a large proportion of clients have a prescribing intervention recorded on the system without a psychosocial intervention alongside it. NICE guidelines state that this should never be the case and that psychosocial interventions greatly increase the chance of successful treatment outcomes. It was agreed that many of these clients had actually been receiving psychosocial work, especially at Harm Minimisation, but that they had not been entered onto the OTIS system. To rectify this, HMS were asked to add the psychosocial interventions onto the system and to backdate them to when they occurred. Almost all of these have now been added to the system, with some being missed in the first data entry exercise. LASARS episodes open alongside Recovery Service Episodes The failed LASARS provider Aquarius left a substantial data gap, as following their departure as providers a substantial amount of data was lost covering the April 2012 March 2013 financial year. This data cannot be recovered. LASARS, a mandatory requirement of the PbR pilot was removed from the treatment system in January 2014, the assessment function has been embedded into the treatment providers function from February Following intensive data mining, an issue was uncovered which was affecting successful treatment figures produced by PHE. The LASARS service were undertaking review Treatment Outcome Profiles (TOP) for the Recovery Service until June 2013 and leaving their episodes open on OTIS alongside the Recovery episodes to allow them to record the TOPs. This relied upon communication between the two services to ensure that the LASARS episode is discharged on or before the date of the Recovery episode. Where this has not been happening the LASARS episode is left open after the Recovery episode and hence the successful completion from Recovery is not counted as NDTMS views the service user as still engaged in treatment. When the LASARS episode is discharged, if the date recorded is after the Recovery episode then the discharge reason from the LASARS episode is used. If they do not enter this as drug/alcohol free or occasional use then the service user will not be counted as a successful completion, even where that has been recorded by the Recovery Service. A later discharge date will delay the completion being 1 This section was completed by Arthur Davis, Data Manager from OCC 5

7 recorded as such and also increase the chance of a service user being recorded as a re-presentation as they will have to not re-present for a longer period. Work was undertaken to correct these episodes so that the LASARS episode was discharged on or before the Recovery Service episode. This led to an increase of 16 drug clients who had successfully completed treatment, bringing the national figures for Oct 12 Sep 13 up from 3.2% to 4.1% for all drug clients. Poor completion of Start TOPs We have encountered an issue with Start TOPs falling out side of the two week window in which a Start TOP must be completed, either side of a structured modality. LASARS were doing Start TOPS then (mainly) referring service users on to the Harm Minimisation Service or the Recovery Service for treatment. If, for any reason, the service user did not appear to start structured treatment at the service within 21 days of LASARS discharge then there will be a perceived gap in treatment which leads to the Start TOP and following Review TOPS not being counted by NDTMS. After analysing the data behind 227 clients who have a gap of greater than 21 days in treatment, it was clear that there are two scenarios which led to inaccurate TOP data on NDTMS submissions. 1. Clients who were in treatment continuously but were re-entered on the system due to data issues caused by LASARS in Clients who genuinely had a gap of greater than 21 days between being assessed at LASARS and beginning structured treatment at a provider. After much consultation with NDTMS around how to solve this issue it has been decided that we need to copy the Start TOP data from the LASARS episode for each client and enter it on the Harm Minimisation, Recovery Service or Howard House episode. This will then increase TOP completion with the aim of reaching 80%, which would allow us to receive further reports from PHE on treatment success rates. To make the data entry as efficient as possible a Crystal report has been created which matches the exact screens on the OTIS system with data from the LASARS TOPs. Despite this, finding the staffing levels to enter the data may be an issue as these need to be resolved by 12th April in order to be submitted to NDTMS in time for national end of year reports. A second point to note for the clients who have a gap in treatment in their data is that they will affect national figures released concerning treatment lengths. These clients will have a current treatment journey of less than 2 years when they could have in fact been in treatment for many years. Creation of local reports Reports have been created locally to facilitate the creation of successful completion figures from OTIS data. Extensive work between the Data Manager and the PHE intelligence team was undertaken to define the intricacies of individual calculations and methodologies, alongside the sharing of client level data to ensure that local figures are created in the exact same way as national figures. 6

8 These reports allow us to keep a much closer eye on progress with improving successful completions, as well as giving the ability to look in more detail at which clients are successfully completing, which service they are completing at, etc. As well as successful completion figures, re-presentation figures are being closely monitored locally. Alongside the increase in successful completions, there has been a rise in clients re-presenting during the period. This is to be expected but must continue to be scrutinised to ensure that the numbers don t carry on rising. Non-Opiate Clients One of the questions raised during this project work was why there national figures were showing a large drop in non-opiate clients successfully completing treatment compared to previous years. Through discussion with service providers and data analysis it was ascertained that this was purely a data recording issue and NOT a performance issue. This was due to the following: 1. The Recovery Service was struggling to know exactly when to discharge these clients. For non-opiate clients, services were leaving clients open in structured treatment on OTIS until they had completely left the service, rather than after they had reached their treatment goals and were only receiving aftercare support. It has now been agreed that services will discharge clients at a more appropriate stage, which should show more realistic numbers of non-opiate clients completing treatment. 2. Previous data was not an accurate reflection of outcomes as the majority of clients were discharged as successful by the previous provider if the service user stayed in treatment for 12 weeks, regardless of the service user treatment goals. 3. The Harm Minimisation Service did not enter non-opiate users on the system for the first 16 months of their contract, therefore there was a significant drop in the number of non-opiate users on the system Analysis of data on clients in the treatment system shows that the majority of non-opiate clients are treatment naïve. Services need to be ensuring that these clients get all the necessary resources to help them achieve their goals whilst the chances of success are at their highest. Alcohol Successful Completions The successful completion figures released from PHE were very low for Oct 2012 Sept 2013 compared to figures run locally. This was raised at a project group meeting and then followed up with PHE. The next release of figures from PHE for Jan 2013 Dec 2013 showed much higher completion levels (up to 14.7% from 5.9%). The most recent figures from PHE for Feb 2013 Jan 2014 have risen again to 16.9%. This is a much more representative figure than those released previously. Transfers Analysis of clients in the treatment system and how they are moving between services has highlighted issues with transfer times in some cases. This can often lead to unsuccessful completions if a client drops out of treatment. Transfer meetings set up between staff from each service are helping to improve communication with the aim of reducing transfer waiting times and disruption to service users. 7

9 Previously on OTIS Howard House sat in a separate consent group from the rest of the treatment services. This meant that not all services could see each others episodes. This was causing issues when transferring clients between services. The issue has now been resolved so that it is clearer where a client currently is in their journey. System Training A training event has been organised for Tuesday 8th April at Recovery Service s offices. This event aims to ensure that all staff who are involved in any work which affects client data, and therefore NDTMS submissions, have a suitable level of understanding of what data NDTMS collect, why they collect it, how it affects national figures and what their role is in inputting data on OTIS. Previous NDTMS training has been targeted at staff in data-centric roles so we are hoping to aim this session more at front line staff and tie it in with the local data system and day to day processes, rather than keeping it at NDTMS level. In summary, from the data work done so far as part of this project, the correction of data issues and a much clearer understanding amongst data managers of the methods which PHE use to create their national figures has provided figures which are much more representative of what is happening in practice. Commissioners and services can now more confidently make use of figures and analysis to inform changes to services and working practices. 8

10 4. SERVICE USER SURVEY An important element to the Improving Recovery Outcomes work in Oxfordshire was to seek feedback from those that use local services and to this end a Service User survey 2 was initiated over the course of late December 2013 and Mid-January The survey had a final sample of 106 local people who were either currently in drug and alcohol treatment services or who had some previous experience of treatment. A final set of 57 Survey open and closed questions were agreed with the Project Team and covered the main themes of: Demography & treatment status Recovery Service User Involvement Multi-agency Working Treatment Prescribing The Survey was led by three local service user representatives who acted as interviewers and used both face to face and telephone interviews to capture information. Demography & Treatment Status The gender split of those who took part in the survey was 70% male and 30% female which broadly mirrors Oxfordshire s current treatment gender make up of 73% and 27% female (as of December 2013). In addition, in order to reflect the diverse geographical and service landscape across Oxfordshire the Survey was conducted with respondents from across all five districts in the County. Figure 1 below provides an overview of where each of the respondents came from. Figure 1 Number of Service Users in Each District The majority of respondents were perhaps not surprisingly from Oxford City reflecting both the clustering of services located within the City but equally the density of the local treatment 2 The full results from the Oxfordshire Service User Survey are available from Oxfordshire County Council 9

11 population. Nonetheless, more rural areas such as Cherwell and South Oxfordshire also scored relatively highly in terms of Survey participants whilst more remote rural areas such as West Oxfordshire and the Vale of White Horse had just a few respondents. RECOMMENDATION: Oxfordshire to look at the current model of delivery in County e.g. satellite provision, outreach, etc in order to establish if this best meets the needs of its population Understanding the age profile of those that use or have experience of local services is a key part of developing an appropriate and responsive local treatment system and Figure 2 below conveys the age ranges of those who took part in the survey. Figure 2 Age Range of Service Users The vast majority of survey participants fit within the age group (60 people or 56% of sample) and again this generally reflects the wider treatment system within the County. However, the survey does show a sizeable proportion of younger clients under the age of 32 (26 people or 24%) who are either in or have experience of treatment. The younger age profile of participants reflected above may have wider implications for services as age has been shown to be a determining factor in client attrition i.e. studies found that younger clients were far more likely to leave treatment in an unplanned way than older clients (Beynon et al, 2007). Thus, ensuring local services can support the needs of this specific population may help to reduce both client attrition and also to improve the overall rate at which people successfully complete treatment. Interestingly, Oxfordshire also has a relatively high number of clients that fit within the older age profile of 53+ (15 people or 14% of total sample) and at least one client who cites their age as being 73+. Respondents were also asked about their current treatment status and given four options to choose from as highlighted by Figure 3 below. 10

12 Figure 3 Treatment Status Relatively high numbers of clients (23 or 22%) cite current status as receiving no treatment and in later discussions with survey interviewers it was a little unclear if this cohort were waiting to access treatment or had not in fact made initial contact with local services. However, further exploration is required to establish why such a high proportion of clients were on the periphery of the treatment system whilst not actively engaged in treatment and whether further assertive outreach approaches could work to engage a potentially large number of identified hard to reach clients. RECOMMENDATION: OCC to establish the extent of Oxfordshire s hard to reach and treatment naive populations and where identified to support development of an assertive outreach / reengagement process to direct /re-direct those clients into the local treatment system It is also useful to point out that the numbers reflected in Figure 3 may involve a number of survey respondents being counted in more than one category as some people cited being in recovery / aftercare and in treatment simultaneously and this might be a true philosophical statement of how they viewed their recovery e.g. treatment equals recovery or may be a misunderstanding of how the question was phrased 3. Recovery Understanding recovery as a concept and equally how to apply it in practice and how to recognize it was a key underlying principle of why the survey was conducted in the first instance. Several questions were posed both in an open and closed question-format under the heading of Current Service Information in order to capture participants views and perspectives on what serviceprovider staff could do to inspire recovery and equally people were also asked to define the concept of recovery for themselves. The responses in terms of what can staff do to inspire recovery are split between practical and more challenging suggestions and these are conveyed in Figures 4 and 5 below. 3 Either way due to a number of people answering this question simultaneously a small number may have been double counted 11

13 Figure 4 below provides an overview of how staff can inspire recovery very much from a practical perspective and generally the suggestions centre on providing more services e.g. more activities, more 1:1 work, more help with mental health issues etc. Additionally, the comments also remark on how services can be structured to match the recovery ambitions of clients i.e. greater use of out of hours for those who are working, speedier access to services etc. Figure 4 Practical Suggestions of How Staff Can Inspire Recovery The practical suggestions outlined above do provide insight into how services might be configured and developed in the future in order to align them much more closely with the recovery aspirations of those they serve e.g. working clients and those with relatively high levels of recovery-capital a group often neglected when it comes to service development. RECOMMENDATION: Service Providers to conduct a service review of the range and quantity of services available to establish the skills set required to deliver the recovery agenda & to establish if services are structured in a way that provides the right platform for recovery e.g. Service Provider opening times, waiting times etc. RECOMMENDATION: Service Providers to incorporate asset-based assessment techniques to support identification of strengths, assets and recovery capital of clients The more challenging comments from survey participants are outline in Figure 5 below. Figure 5 Challenging Suggestions as to how staff can Inspire Recovery t. 12

14 The survey comments reflected in Figure 5 above are more direct in terms of what can inspire recovery and generally these comments suggest service users want to see recovery in action through staff exhibiting a range of professional-behaviours e.g. acknowledging and responding to telephone calls and messages but equally about staff being able to talk knowledgably and cogently about recovery as a concept. Such comments might be encapsulated in the phrase show and tell meaning that recovery within this context is as much about the way services are perceived outwardly by service users i.e. being ordered and professional ( the show ) as it is about the level of understanding of recovery by staff themselves ( the tell ). RECOMMENDATION: Development of Service Provider Training that targets behaviours, attitudes & how to make most of early client contact with services Survey participants were also asked to define recovery from their own personal perspective and Figure 6 below provides an overview of the collated responses. Figure 6 Survey Respondents Definitions of Recovery On the whole the responses contained in Figure 6 above can be grouped into state of mind and self-belief statements such as recovery being free from active addiction and it being a totally life altering experience to more personal statements such as a recovery providing the opportunity to bring about closure on past abuse and offering the space for improved mental health. The repetition and close association between often very tragic and traumatic personal histories and dependent substance misuse was something that came up frequently throughout the service user survey and suggests a level of behavioural complexity amongst a proportion of Oxfordshire s treatment population beyond that of just addiction. As a consequence, managing such complexity requires an integrated, system-wide response and this involves both drug and alcohol treatment services and those beyond the treatment system to act cohesively in order to tackle addiction as a multi-factorial rather than as a single issue problem. RECOMMENDATION: Oxfordshire County Council to review its integrated care pathways between specialist, generalist and periphery services to establish if there are ways to improve client movement between services Treatment 13

15 The quality of the treatment experience both in terms of first-impressions and prolonged exposure has been highlighted by several research studies as the single most important factor in whether service users achieve a successful outcome or not (Hubbard, R.L et al, 1997; Simpson, D.D. et al, 1997; Gossop, M. et al, 2001). In a series of papers entitled, Manners Matter, Drugscope wrote extensively on the need for drug and alcohol services to be cognisant of the needs of service users in terms of first impressions coining the phrase services with manners and thus indicating the importance of creating a warm and welcoming environment in order to retain clients in treatment (Manners Matter, 2001). Hence, a significant proportion of the Oxfordshire s Service User Survey focused on service users experiences of treatment and Figure 7 below provides an overview of how people rated their first introduction to local services. Figure 7 Survey Respondents rating of first introduction to Services Clearly, the majority of respondents felt local services had provided a welcoming experience and as Figure 8 below suggests when asked to put this experience into a statement, phrase or additional narrative service users were overwhelmingly positive in their responses. Figure 8 Postive Experiences of Treatnment 14

16 Respondents described local service provider staff as acting kindly and as being more sympathetic than expected and as providing a service without prejudice. The lasting impression conveyed by such comments is that broadly Oxfordshire has a local treatment system that is viewed positively by those that use it and is commensurate with service-user expectations. Nonetheless, a sizable minority of clients (approximately 10-15% of the survey sample) cited a range of negative experiences and these are outlined in Figure 9 below. Figure 9: Negative Experiences of Treatment The quality of the first experience of treatment is important and has already been highlighted above but where negative treatment experiences lead to client attrition and result in people revolving around and re-entering the system on multiple occasions may result in an increased level of client complexity not otherwise present, as outlined in Oxfordshire s recently published Recovery Diagnostic Toolkit (Recovery Diagnostic Toolkit, PHE, 2013). RECOMMENDATION: Local Services to ensure that previous treatment history including frequency and rate of unplanned departures are incorporated into assessment processes and recovery planning reflects the need for an individualised and differential approach Service User Involvement Creating service user involvement and providing local forums for the recipients of commissioned services to have their say is an essential part of any drug and alcohol system and consequently survey participants were asked a series of questions about service user involvement including if they were actively engaged in local service user groups as reflected in Figure 10 below. 15

17 Figure 10: Involvement in Service User Groups Surprisingly, a majority of respondents stated that they were not involved in any service user Group in Oxfordshire despite there being a County-wide group in existence as well as a range of smaller support groups present in almost all of the five districts. RECOMMENDATION: Service User representatives to review how current County-Wide Group might be strengthened and developed in order to create a single unified Group that provides a voice for people using Oxfordshire s treatment services Multi-Agency Working In order to understand how local services work with each other the survey posed a number of questions around multi-agency and integrated working including how effective the communication was between agencies, as conveyed in Figure 11 below. Figure 11: Communication between Agencies The vast majority of respondents (66%) suggested that communication between agencies was not effective but of course this may include agencies beyond that of the commissioned drug and alcohol treatment system and thus potentially beyond the scope of this report. Nonetheless, as inter-agency communication is a key part of how services gather client information especially at the beginning of 16

18 treatment i.e. through assessments etc. it is vital that organizations have mechanisms and protocols in place that allow for clear and timely client information to be exchanged. RECOMMENDATION: All Providers to review and audit their communications with service users, family and other professionals at every level of service provision including information sharing protocols RECOMMENDATION: All services to review literature & other promotional material to establish quality and availability RECOMMENDATION: Services to create inter-agency staff shadowing opportunities e.g. as part of induction in order to improve inter-organizational understanding Prescribing Opioid Substitution Therapy (OST) is a key clinical intervention in Oxfordshire with approximately 1400 clients being prescribing at any one time. Thus, gathering information on this population and seeking feedback from them on how they want to see OST improved upon was the key focus of the final set of questions in the survey. Figure 12 below provides an overview of OST duration. Figure 12: Prescription Duration The majority of participants that responded to this question stated they had been on a prescribing regime for less than a year with the second largest group in the six years plus category. The chart contained in Figure 12 above mirrors the latest RDT (Recovery Diagnostic Toolkit) data for Oxfordshire and as such local service providers are already aware of the need to develop an appropriate service response that can address the different needs of these two very distinct client groups. RECOMMENDATION: Ensure that prescribing interventions are optimised by offering a broad range of provision alongside clinical interventions especially psycho-social support RECOMMENDATION: Phasing and Layering approaches to be adopted by Service Providers to support differential approaches to working with segmented populations e.g. under 1 year and 6 years plus 17

19 Survey respondents were also asked to provide suggestions for how prescribing services could be improved upon and Figure 13 below captures the full range of responses. Figure 13: Survey Respondents suggestions for improving prescribing services A majority of survey participants wanted to see prescribing services that were more personalised and which offered a greater array of therapeutic and psycho-social interventions such as counselling and additional peer support groups. Creating rapid access to prescribing services was also flagged as an important area for improvement as was the need for services to be flexible and for staff / keyworker to have the right attitude. RECOMMENDATION: Local services to review recovery planning processes to ensure that all clients feel involved in the care they receive RECOMMENDATION: Services to review waiting times for access to OST provision RECOMMENDATION: Recruit peer supporters / Recovery Mentors to work alongside clients in prescribing services in order to make successful completion & recovery more visible RECOMMENDATION: Services to develop or extend procedures that support rapid re-capture / reengagement of clients where modality attrition has taken place 18

20 5. OXFORDSHIRE DRUG & ALCOHOL CLINICAL PRACTICE EVENT Oxfordshire has one the largest shared care schemes in the country with around 750 Opioid Substitution Therapy (OST) patients treated within a primary care at any one time but shared care also has one of the lowest rates of successful completions of the whole treatment system. The event attracted an audience of around 80 with representation from a range of key local GPs and Clinicians as well as other interested stakeholder groups. The event centred on raising knowledge and understanding amongst GPs and Clinicians on best practice evidence with a substantial part of the event given over to looking at NICE Clinical Guidelines and at the research base supporting the provision of effective pharmacotherapy and psycho-social interventions. The event focused on the following key objectives: Exploring evidence base for OST within the context of Oxfordshire; Examining the effective models of practice for motivating clients towards recovery; Sharing a what works approach in the treatment of specific groups e.g. clients new to treatment, those in treatment for 4yrs or longer & those with complex prescribing needs; How to implement best practice in reviewing drug and alcohol treatment. The two lead Clinicians presenting at the event were Dr Mike Kelleher and Dr Luke Mitcheson 4 and both generated discussions across all of the above key objective areas with particular emphasis on delivering effective clinical and psycho-social practice within a primary care setting. In his presentation, Dr Kelleher alluded to several important research studies (Kakko J, Grönbladh L, Svanborg KD et al, 2007) 5 that support the notion of combined and intensive pharmacotherapy and psycho-social support within the first three months of treatment. In the ensuing discussions, a number of points were made around the need to ensure that pharmacotherapy was provided alongside good and effective psycho-social interventions and also how local services could support this work in order to improve recovery outcomes for patients. RECOMMENDATION: Service Providers to review case files of Shared Care patients in order to identify those who are within the first 3-6 months of treatment & to re-assess recovery plans in order to highlight areas where intensity and frequency of psycho-social interventions might be strengthened In addition, Dr Kelleher also alluded to clinical practice guidelines (NICE, 2009; Strang, 2012) and how these might be implemented in order to support patients in their treatment and recovery journeys and how local services might work to align themselves more closely to these best practice principles. In particular, Dr Kelleher referred to the phasing and layering of treatment outlined in the Medications in Recovery Report 6 published by the RODT Group in 2012 and how these adaptive 4 Dr Michael Kelleher, Clinical Lead, Alcohol and Drugs Team, Health and Wellbeing Directorate; Dr Luke Mitcheson, Consultant Clinical Psychologist 5 Kakko J, Grönbladh L, Svanborg KD et al. (2007) Am J Psychiatry 2007; 164:

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