MAKING RECOVERY REAL: THE PUBLIC HEALTH FUTURE OF DRUG AND ALCOHOL TREATMENT

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1 MAKING RECOVERY REAL: THE PUBLIC HEALTH FUTURE OF DRUG AND ALCOHOL TREATMENT

2 Drug treatment in England: a decade of achievement Overall drug use in England is down There are fewer heroin and crack users Fewer people are in treatment for drug use Average waiting times have plummeted More drug users are recovering from addiction Younger people are turning away from the most harmful drugs Drug-related crime is down

3 April 2013: new landscape, new challenges Money competing priorities for local authorities, risk of disinvestment NHS restructured, resource pressured Integration of alcohol and drug treatment Newer drugs future impact on treatment unclear Jobs and houses economic and political climate Staff competence ability to deliver against higher expectations

4 Drugs and alcohol within public health: a good fit Public health has been through waves of development, with new priorities but continuing attention to past priorities: 1. engineering clean water and sanitation 2. understanding and tackling infections 3. building universal health and welfare services 4. reducing lifestyle risk factors for disease 5. promoting individual and community wellbeing Drug and alcohol treatment is similarly diverse and developing, and shares public health s methods and interests

5 Public Health England: leadership and support All the NTA s expertise, support, data and tools will be available from PHE Leadership on alcohol treatment > closer integration with drug treatment, medicines as well as illicit drugs The performance of drug and alcohol treatment continues to be a key measure in national outcome indicators that will be closely monitored by ministers

6 The funding what has gone into the public health grant Pooled drug treatment budget 400m Department of Health DIP funding 60m Young people s substance misuse treatment 25m Local drug treatment spend 160m Alcohol Prison substance misuse treatment Home Office DIP funding tba* 2010 allocation (in blue) and other health spend on substance misuse that has become part of the 2.6bn public health grant 100m NHS Commissioning Board 35m Police & Crime Commissioners (All figures approximate and rounded) *Pegged to local submissions and based on 2010/11 figures

7 The task for the sector Drugs and alcohol agenda will need to be championed, strategic partners engaged Priorities will need to be balanced: treatment for drugs, alcohol, addiction to medicines prevention activity Delivery will need to be informed by evidence of what works Recovery ambition will need to be maintained and strengthened Existing health gains will need to be protected

8 MEDICATIONS IN RECOVERY

9 Recovery: Government signals the new ambition 2010 Drug Strategy: Substitute prescribing continues to have a role to play in the treatment of heroin dependence, both in stabilising drug use and supporting detoxification. Medically-assisted recovery can, and does, happen.... However, for too many people currently on a substitute prescription, what should be the first step on the journey to recovery risks ending there. This must change.

10 Identifying a way forward: the expert group In 2010 the NTA asked Professor John Strang, Director of the National Addiction Centre, to chair a group to provide guidance on the proper use of medications to aid recovery The Recovery Orientated Drug Treatment Expert Group comprised clinicians, managers, service user representatives, commissioners, researchers and others Final report published July 2012

11 The expert group s final report July 2012 The ambition for more people to recover is legitimate, deliverable and overdue The existence of an accessible, evidence-based drug treatment system in every part of England gives us an excellent opportunity to improve on the past by using international historic evidence as the floor for our ambition and not its ceiling.

12 The report s key findings Much has been achieved by England s drug treatment system since 2001 in improving people s health However heroin is an especially tenacious and habitforming drug and many people haven t recovered Used well, opioid substitution treatment is effective but should be a platform for recovery, not an end in itself Leaving treatment is significant but it isn t recovery important not to end treatment too early Some people recover quickly, some don t all need recovery support

13 The evidence base for OST The evidence is good that OST: Retains people in treatment Suppresses illicit use of heroin Reduces crime Reduces the risk of BBV Reduces risk of death The evidence is less persuasive that OST: Suppresses other drug use Improves physical and mental health Improves social reintegration of marginalised heroin users Promotes abstinence from all drugs

14 The relationship between medication and recovery Recovery status is best defined by factors other than medication status. Neither medication assisted treatment of opioid addiction nor the cessation of such treatment by itself constitute recovery. Recovery status instead hinges on broader achievements in health and social functioning - with or without medication support. A Thomas McLellan & William White

15 A platform of stability, not an end in itself Well-delivered OST provides a platform of stability and safety that protects people and creates the time and space for them to move forward in their personal recovery journeys. OST has an important and legitimate place within a recovery orientated system of care. We need to ensure OST is the best platform it can be but focus equally on the quality, range and purposeful management of the broader package of care it sits within. Medications in Recovery, July 2012

16 Key elements of a successful treatment service A shared vision of recovery, and leadership Organisations & staff able to support and sustain change Staff who believe in the treatment they are delivering A structured programme with clear treatment goals Availability and range of OST medications Range and quality of psychosocial interventions Active referral to self help and mutual aid Links to recovery orientated community organisations

17 Effective delivery of OST Ensure adequate dose this should be individually tailored to take account of factors such as increased metabolism in some people Ensure medication is being taken as prescribed use supervised consumption and drug testing as appropriate Deploy contingency management to stop use on top Keep challenging all clients, even (and especially) those apparently stuck everyone deserves the chance to recover

18 Beyond OST: what should services do? Do more use a range of tailored interventions Do it quickly for those new in treatment Evidence shows greatest improvement is achieved during first three months Getting treatment right during this period vital to the recovery process But avoid unintended consequences This is not about destabilising, to the point of unacceptable risk, individuals who are deriving benefit from OST

19 Treatment needs to be dynamic, phased and layered Plan, review and optimise care using measures of recovery Phase or sequence care to deliver different interventions appropriate to different stages in the treatment and recovery journey Layer in different intensities of treatment, stepping up or down according to need, choice, efficacy and progress Ensure treatment can be fine-tuned within an intensity layer by being able to adapt or optimise treatment

20 The implementation challenge Implementing new interventions and ways of working is challenging: Takes continued effort to translate and embed evidencebased approaches in routine clinical practice Requires synergy between: Leadership A culture of innovation Governance Training Supervision

21 Staff equipped to achieve better outcomes Evidence* suggests: Workers who have clear techniques and belief in them achieve better outcomes (goals and structure) Supervision and governance are key Outcomes are greatly influenced by the quality of the working alliance *Wampold (2001), Bell (1998), Moos (2003) Metacompetences: Competent practitioners of psychosocial interventions implement higher-order links between theory and practice in order to plan and guide their practice and, where necessary, adapt an intervention to individual needs. Pilling S, Hesketh K & Mitcheson L (2010)

22 Focus on process more than specific interventions Effective treatment more likely with a knowledgeable, efficient, likeable and encouraging helper who helps: reinforce the feeling of need for change (e.g. encourage discrepancy ) develop commitment to change (e.g. pledges, change statements ) develop self-efficacy (e.g. self liberation, seeing the benefits ) build social support for change. Orford J (2011)

23 Recovery support is integral to treatment Peer role models and peer support Employment support Family and social networks Housing support Improving wellbeing Post-treatment support

24 The importance of social reintegration Formal treatment can be a powerful factor in building social support and psychological resources to facilitate positive change, but on its own it typically does not have a lasting influence. (Moos, 2003) People need alternative rewards in their lives People who achieve good social reintegration, particularly employment, are more likely to leave treatment without relapse. (Milby, 1988)

25 Treatment and recovery communities Recovery communities can provide the social cure Treatment and recovery communities need to be better integrated NICE recommended that Staff should routinely provide people who misuse drugs with information about self-help groups. These groups should normally be based on 12-step principles; for example, Narcotics Anonymous and Cocaine Anonymous.

26 Potential benefits of treatment and mutual aid working together Keep me alive and out of prison Take me to a mutual aid meeting. Connect me to a recovery community (NA, SMART, etc) Take me on as a volunteer taking other people to mutual aid meetings and connecting them to recovery communities

27 DELIVERING ON THE ALCOHOL AGENDA

28 The problem and the opportunity Alcohol misuse is widespread: 7 million adults in England drink at levels that increase the risk of harm to their health 1.6 million show some signs of alcohol dependence The move to Public Health England and local authority-led commissioning opens up new opportunities for integrated delivery of drug and alcohol treatment.

29 Aims of the 2012 alcohol strategy Change behaviour so people think it is not acceptable to drink in ways that cause themselves or others harm Reduce alcohol-fuelled violent crime Reduce the number of adults drinking above NHS guidelines Reduce the number of people binge drinking Reduce the number of alcoholrelated deaths Sustain reduction in both the numbers of years olds drinking and the amounts they consume

30 Local delivery of the alcohol strategy The strategy encourages local government, NHS, PCCs and other partners to work together to use their new powers and responsibilities Public health grant to be used to address problems of alcohol misuse Linking to funding via NHS Commissioning Board and CCGs for IBA and hospital based services

31 A complex system with complex funding Supply reduction Child protection LA LA/PHE Prison NCB Mental health CCG Demand reduction Outlet density Minimum pricing LA-Licensing IBA CCG LA/PHE NCB Community Treatment LA/PHE Residential LA/PHE Acute Sector CCG ATR Probation NOMS LA/PHE Adult safeguarding LA 31

32 Alcohol treatment in the new public health landscape A quality treatment system driven by local need Delivered in accordance with NICE and other guidance Informed and underpinned by evidence: NATMS Appropriately commissioned Appropriately qualified staff Recovery focused Wide range of interventions; mutual aid Integrated Within PHE; across multiple domains

33 Support for successful delivery NTA is providing support to commissioners and directors of public health via regional alcohol networks, focusing on the High Impact Changes: Identification and Brief Advice hospital-based services NICE-compliant specialist treatment NTA is working with 14 areas in more depth, building on the work of the Alcohol Improvement Programme Holding stakeholder events focusing on key delivery themes Providing tools to support delivery

34 Essential resources Recovery Resources for commissioning Medications in recovery: re-orientating drug dependence treatment NICE guidance: Drugs Methadone and buprenorphine Naltrexone Psychosocial interventions Detoxification Alcohol Alcohol use disorders: preventing harmful drinking Alcohol-use disorders: physical complications Alcohol dependence and harmful alcohol use Improving interventions and the competences to deliver them: NTA/BPS framework and toolkit for NICE psychosocial interventions Alcohol Learning Centre Substance Misuse Skills Consortium skills framework and Skills Hub

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