Addressing Substance Abuse Treatment in the United States. Insights from the UK

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1 Addressing Substance Abuse Treatment in the United States Insights from the UK A Mi-Case white paper: January 2012

2 Contents Introduction... 2 The US transformative vision for substance abuse treatment... 2 Substance abuse treatment and the healthcare reform... 3 HIT (Health Information Technology) and EHR in Substance Abuse Treatment... 4 Bringing treatment to the criminal justice system... 5 The British experience in substance abuse treatment... 7 Characteristics of the UK substance abuse treatment system... 7 Treatment in the criminal justice system... 9 IT modernisation of substance abuse treatment in the UK Benefits from substance abuse treatment in the UK Similarities between US and UK substance abuse treatment systems Page 1

3 Introduction The United States and the UK face similar health and socio-economic issues, among which are the issues of tackling substance use disorders. As a complex social and economic problem, substance abuse affects a diverse range of groups bringing enormous costs to society through the criminal justice, health, social welfare and the economic system. To combat this, both countries have adopted a multi-agency approach to the problem that fosters collaborative delivery of substance abuse treatment services in local communities. With recent health legislative changes in the US, historical differences in the legal approaches to substance use problems seem to be disappearing too: as punitive laws proved to have little impact on drug use in the past, the country is steadily transiting to more lenient, medical and treatment-oriented policies which already have been successfully implemented in the UK over the last decade. To improve the capacity for delivery of high-quality treatment services, the on-going US healthcare reform is focused on improving the information technology support for substance abuse treatment providers, in particular by supporting the development and upgrade of treatment providers client information systems and their integration with EHRs (Electronic Health Records) and broader health systems. And again, in the UK, the adoption of multi-agency substance abuse treatment information systems in community and custody environments has already proved to be successful, with many agencies realising enormous benefits from streamlined, better coordinated and more cost-effective delivery of treatment services. Deeper understanding of the UK approach and experience in the delivery of multi-agency substance abuse treatment services may help the United States in realising their treatment strategies and achieving their vision more quickly and effectively. This paper will aim to identify the similarities between the two nations domain systems and to bring some insight to US substance abuse treatment stakeholders into the experiences, best practices and benefits from similar developments in the treatment area in the UK. The US transformative vision for substance abuse treatment The United States have some of the highest rates of substance abuse in the world, which cause serious, pervasive and expensive problems in the country. In 2007, the last year for which a complete set of data is available, the estimated economic impact of illicit drug use on American society was more than $193 billion. 1 From this, the cost of treating drug abuse through public health was estimated at $11.5 billion a fraction of the overall costs to society, whereas $61.4 billion were associated with drug-related crime (out of which $56.5 billion were costs for processing drug offenders through the criminal justice system). These figures are a reflection of the country s longlasting coercive approach to this problem characterised mostly with punishment and incarceration rather than treatment; an approach which didn t return many useful results and forced the country to shift the focus slowly from full-scale law enforcement to an evolved, more balanced approach that emphasizes a combination of prevention, treatment, and law enforcement interventions 2. 1 US DOJ, The Economic Impact of Illicit Drug Use on American Society 2011, 2 ONDCP, US Government, National Drug Control Strategy , Page 2

4 A number of substance related policy developments brought out recently by the US government aim to actuate this new approach. Favourable legislative initiatives can be found across many sectors including criminal justice, health, social welfare and education, but key changes that bring further investments and improvement to addiction treatment services include: Expanding access to treatment through early intervention programs in healthcare Integration of evidence-based treatment for substance use disorders into mainstream health care Increasing adoption of health information technology and EHRs by substance abuse treatment providers Focus on community-based long-term recovery and wellbeing Aligning criminal justice policies and public health systems through a multi-agency approach to: divert non-violent drug offenders into treatment instead of jail, provide treatment in jails and support re-entry in community The National Drug Control Strategy 2010 unifies together all nation-wide efforts in tackling drug use problems under one umbrella, in particular trying to ensure a) integration of substance abuse treatment into mainstream healthcare and b) alignment between the criminal justice and healthcare system. Substance abuse treatment and the healthcare reform For many years there was a great divide between substance abuse treatment programs and the mainstream health care system in the US. Addiction was seen more as a moral issue rather than a primary and chronic disease that can be prevented and treated. This isolation of treatment programs has taken the emphasis away from the development of personnel, information systems, medication and infrastructure within the specialty substance abuse treatment care system, which resulted in lack of resources and insufficient capacity of most programs to provide contemporary evidencebased care. In 2009, only about 10% of the 23 million people diagnosed with substance use disorders received specialty treatment 3, indicating that changes were needed to increase the accessibility, affordability and quality of treatment services. The current healthcare reform is trying to tackle this problem by providing mechanisms and incentives that drive integration of substance abuse programs into mainstream medicine. Under the Affordable Care Act 2010, substance use disorders and addictions are recognised as chronic disease disorders that need to be treated like other chronic diseases. As such, this Act provides mechanisms to help increase the access, volume and quality of substance abuse treatment services. These include actions such as co-locating treatment services with other primary care services, training staff to provide high-quality treatment services in main healthcare centres and coordinating services and information about patients across all healthcare providers. And most importantly, to ensure the realisation of these actions in practice, the Act provides parity for insurance coverage of substance abuse problems making treatment services accessible to a large number of low-income people who are most seriously affected by the problem but couldn t afford to treat it previously. In specific, by including substance use disorders as one of the ten elements of essential health benefits in 2014, 3 Substance Abuse and Mental Health Services Administration (2010), Results from the 2009 National Survey on Drug Use and Health: Summary of national findings Vol. 1, Office of Applied Studies, NSDUH Series H-38A, HHS Publication No. SMA Findings, Rockville, MD. Page 3

5 the Affordable Care Act will provide access to health insurance coverage for additional 6-10 million uninsured people with substance use problems 4. In 2009 President Obama lifted the ban on most Federal funding for needle exchange programs 5 designating the adoption of harm reduction policies which for long time were prohibited in the US. This was another initiative that improved the access to substance abuse treatment services for Injection Drug Users, as needle exchange programmes are normally the first point of contact for drug treatment providing access to health and counselling service referrals. The integration of these programmes in comprehensive public health systems means that treatment providers will have to develop or adjust their existing information systems to support the delivery of these types of programmes too. These changes put increased pressure on treatment service providers for standardised and better quality services but also bring more public funding for the sector in particular for those providers who can provide high-quality treatment services. This brings us to another set of initiatives for improving the quality of treatment services including development of national quality standards and pay-for-performance mechanisms that reward providers who implement evidence-based standardised practices and promote recovery. Recovery is the central topic of discussion in drug policy in the US Administration. Treatment that leads to recovery is the ultimate goal, and a number of initiatives have been started to expand access to community-based recovery programmes such as counselling, coaching, transportation, housing, employment etc. Funding is increasingly provided for innovative delivery of recovery services through information technology, which is deemed to be the most cost-effective way for building and expanding the infrastructure of sustainable recovery frameworks. HIT (Health Information Technology) and EHR in Substance Abuse Treatment One of the key components of the healthcare reform is Health Information Technology and in particular the establishment of Electronic Health Records (EHRs). Both the American Recovery and Reinvestment Act and the Affordable Care Act are driving health systems toward the use of information technology for service delivery, as IT is seen as the key mechanism for service quality improvement, cost reduction, and increased control of patient health care and related information. The implementation of EHRs in particular, should allow for the integration of substance use treatment records into patients medical records, supporting the exchange of substance use information among medical professionals. However, in the past, the isolation of the substance abuse domain from the mainstream healthcare was followed with slower development of information technology than the average development in general healthcare practices. As result, many treatment providers have weak IT infrastructure today with many professionals using paper-based systems and patients records. In 2009, about 20% of substance abuse treatment programmes had no information system and less than half of the providers had fully implemented electronic records systems 6. This presents a significant impediment for the integration of substance use treatment into the primary care system mainly because without Page 4

6 established EHRs, treatment providers cannot connect to state-wide health information technology systems, and more importantly are not eligible for reimbursement for health services. To combat this problem, SAMHSA (the Substance Abuse and Mental Health Services Administration) is supporting the adoption of HIT and EHRs with treatment providers by a) providing guides and funding for development and upgrade of providers information systems and patient records, and b) developing policies and guidance to support their integration with broader health systems, taking in account patients privacy issues in particular. Patient privacy issues are of paramount importance in the substance abuse domain, due to the sensitivity of this information and the social stigma associated with substance use disorders and their treatment. Technology used in patient information systems has crucial role in ensuring absolute privacy and security of patients confidential information. Treatment agencies can ensure they meet stringent privacy regulations by choosing experienced technology providers whose systems protect privacy and provide security of patient s data in compliance with all government regulations. The HIPAA (Health Insurance Portability and Accountability Act) regulations in particular, set the key compliancy requirements for privacy, confidentiality and security of providers clinical information, requiring documentation of all requests and transfers of patient information. One of the wider government mechanisms to facilitate the adoption of HIT and EHRs with substance abuse functionality in general and specialty healthcare settings, is the introduction of the SBIRT (screening, brief intervention, and referral to treatment) tool which enables health care professionals to recognise early intervention opportunities. Although studies show that the introduction of screening and early intervention tools reduce overall healthcare costs and are far more effective in reducing substance use than the treatment of advanced substance use disease, the adoption of SBIRT across the states has been very slow mostly due to lack of knowledge about SBIRT and limits on its reimbursement. For this reason the government is providing further incentives, tools and training to facilitate increased adoption of SBIRT in primary healthcare. The development of standardized electronic patient SBIRT forms, both in primary care and specialty treatment providers applications, is one of the key measures facilitating faster adoption of the tool among practitioners. The expansion and standardisation of electronic Prescription Drug Monitoring Systems on state level and their integration with EHRs will also bring future developments for treatment providers who will have to ensure that their systems can support the integration of patient s health record with patient s prescriptions to help reduce prescription drug abuse problems. All these IT initiatives clearly show the focus of the American government on modernizing and improving the health information systems in the substance abuse domain, supporting it with numerous grant programmes to incentivise faster adoption among healthcare providers. Bringing treatment to the criminal justice system The strong connection between offending and substance use makes the criminal justice system a great place to tackle the problem of substance abuse. About 50% of offenders in the American criminal justice system are classified as being dependent on drugs, which gives a rough estimate of 3.5 million drug offenders in the US 7. Having recognised this, the US government is putting efforts on aligning the criminal justice and public health systems to reduce the number of drug offenders by 7 Page 5

7 extending treatment in custody and community corrections environments. In the past, incarceration was the key response to dealing with drug offences in the US, but in recent years the government is exploring alternative options to incarceration, from pre-trial diversions to community re-entry programmes, targeted at offenders with underlying substance use disorders. These developments, experts suggest, could be seen as part of a broader move away from criminalization towards more pragmatic therapeutic approaches for drug abusers 8, so typical for the UK substance abuse system. In the past years, the US government has developed a range of substance treatment initiatives in the criminal justice sector, some of which have already proved to be effective and widely adopted across the states (such as the use of drug courts), whereas others are testing models which need further refinement and wider adoption to become best practices. Recent initiatives, similar to those already effective in the UK, include: Development of infrastructure that will support the delivery of alternative programmes to incarceration for low-level drug-using offenders. For these programmes to work, a multiinstitutional approach needs to be adopted which presumes collaboration with agencies outside the criminal justice system (ex. healthcare and social welfare). New initiative based on a multiinstitutional approach addresses public health in the criminal justice system by expanding screening tools (SBIRT) for occurring substance use problems in offender population which helps identified drug offenders to get into treatment. Further funding to promote adoption of the TASC (Treatment Alternatives for Safe Communities) Model of Intensive Case Management. This model integrates the criminal justice and substance abuse treatment systems to more effectively help individuals as they move through criminal processing, correctional supervision, and aftercare. It provides substantial cost-savings through individualised case plans that include links to community-based substance abuse treatment and other social services initiating behavioural change and long-term recovery for individuals in the criminal justice system. Improvement of coordination of re-entry support services for persons re-entering the community from jail or prison to enable their successful reintegration into society. Further investment to improve the operation of existing and support development of new Drug and Community problem-solving courts, which are proved cost-effective alternative to traditional incarceration. Delivery of substance abuse treatment programmes in prisons and Drug testing and sanctioning for offenders on parole and probation. This integrated approach to dealing with the substance abuse problem through interventions and treatment situated in the criminal justice system creates requirements for treatment providers to extend their capabilities if interested to provide services in criminal justice settings. Most importantly, providers information system will need to be further adjusted to meet the specific requirements of emerging programmes in criminal justice. Even more, as information systems become more integrated and centralised, deeper integration and interoperability between offender management and substance abuse information systems is to be expected in near future. 8 Page 6

8 The British experience in substance abuse treatment Compared to US, British substance abuse policy has followed a less punitive and more treatment based approach to the problem of substance misuse throughout history. This treatment-focused policy has necessitated greater investments in treatment than those in the US for more than a decade, leading to a mature and well-established substance abuse treatment system. In comparison, the dramatic increase in treatment capacity in the UK allowed for 75% of the government s estimated number of problematic drug users to get in contact with structured treatment in , whereas in the US only 10% of the estimated drug users needing treatment actually received treatment in the same year 10. Also, the UK drug policy has been more openly oriented toward a harm-minimisation perspective in defining the objectives of treatment, which for many years was forbidden in the US. In fact, needle exchange programmes have been delivering community health benefits for almost 30 years in the UK whereas in the US they have been approved only 2 years ago. The British advancement in the substance abuse treatment system means that there is a great opportunity for US treatment providers to examine other country s experiences in delivering successful treatment programmes, and possibly adopt their best practices or avoid practices that don t work. However, there is a two-way relation between the two systems; in the mid-1990s, increased criminalisation of British drug users started, not exclusively by incarcerating drug users but by introducing drug testing and treatment to offenders at every stage of the criminal justice system, from arrest and bail through sentencing to incarceration or community supervision 11. As result the current approach to drugs and addiction is heavily focused on crime and interventions based in the criminal justice system, practice which is also present in the US substance abuse treatment system. These developments show an emerging convergence in the drug policies between the two countries 12 and remarkable similarities in the adopted treatment delivery approaches making the transfer of knowledge and best practices between them viable and extremely useful. Characteristics of the UK substance abuse treatment system Over the last few decades UK government has emphasised the role of treatment in reducing drug dependence and high-level harms associated with it. Through the years, and due to advancements in treatment practices, the focus of policies has changed slightly: initially, substance abuse treatment policies were focused on increasing access to treatment and getting more drug and alcohol users into treatment, whereas in recent years focus has been given to the quality and effectiveness of treatment by development of more personalised approaches to treatment services that are focused on recovery. Investments made in the substance abuse treatment system in the last decade have expanded capacity substantially resulting in increase in treatment enrolment of approximately 110% 13. The Drug strategy from 2010 instead, is focused on creating a recovery system that helps 9 National Treatment Agency (NTA) 2009, The story of Drug Treatment, 10 Substance Abuse and Mental Health Services Administration (2010), Results from the 2009 National Survey on Drug Use and Health: Summary of national findings Vol. 1, Office of Applied Studies, NSDUH Series H-38A, HHS Publication No. SMA Findings, Rockville, MD. 11 Boldt, Richard C. (2011)., Drug Policy in Context: Rhetoric and Practice in the United States and the United Kingdom, South Carolina Law Review, Vol. 62, p. 261, 2011; U of Maryland Legal Studies Research Paper No Ibid. 13 Reuter, P. and Stevens, A. (2007) An Analysis of UK Drug Policy: A monograph prepared for the UK drug policy commission, London: UK Drug Policy Commission Page 7

9 people not only to get into treatment and meet process-driven targets, but also to get into full recovery and off drugs and alcohol for good. Key characteristics of the UK substance abuse treatment system include: Focus on recovery and outcomes - Key feature of the recovery oriented treatment system is the focus on outcomes. England is leading the way internationally on drug treatment outcomes work and is one of a few countries in the world where there is a national system for recording the outcomes of people currently undergoing treatment. Measurement of outcomes is done with the Treatment Outcomes Profile (TOP) tool which is increasingly being implemented in countries around the world due to its effectiveness and flexibility. TOP is a clinically-validated monitoring tool that tracks the progress of individuals through their treatment journey, which instead of measuring proxy process-driven metrics, measures real treatment outcomes in the areas of drug use, injecting risk behaviour, health, social functioning and self-reported criminal activity. Currently, the government is focused on strengthening the recovery and outcome focused approach by introducing a new performance measurement scheme - Payment by Result (PbR) - which means that providers will no longer be paid simply on process activity but on the outcomes they achieve. Partnership approach Since 1998, all UK substance abuse strategies have emphasised partnership approaches to the substance abuse problem, effective both on policy development and local delivery level. Responsibility for local delivery of drug strategies has been given to multi-agency Drug Action Teams (DATs) in England and similar bodies in Scotland and Wales. These multi-agency DATs normally consist of representatives from the National Health Service (NHS), mental health and primary care trusts, local authorities, the police, the probation service, and the voluntary sector, working together to create suitable integrated care plans for individuals that meet their varied needs beyond the need for treatment, ensure their continuity of care and re-integration in community. Governance UK substance abuse policy cuts across the work of several government departments, including the Department of Health, the Home Office, Department of Education, Ministry of Justice and the Department of Work and Pensions. As result, a centralised agency has been established (the National Treatment Agency NTA) as part of NHS in England, which has a central role in coordinating the delivery of treatment services through its regional offices. On local level, treatment services are commissioned by 149 local partnerships, known as Drug Action Teams (DATs) supported by the regional NTA teams. A mixture of NHS and voluntary sector providers can be commissioned by the DATs to supply the actual treatment. Funding Substance abuse treatment services in the UK are funded mostly through a combined central government funding from the criminal justice and healthcare system, and the rest is supplemented locally by local authorities and NHS (National Health Service) Primary Care Trusts 14. Funding is allocated to local Drug Action Teams (DATs) annually through the NTA on the basis of area deprivation factors to ensure that money goes to those areas that are most in need. The existence of this public funding model is the key factor for the success of the UK substance abuse treatment 14 The National Health Service or NHS is the publicly funded healthcare system in England. An NHS primary care trust (PCT) is a type of NHS trust, part of the National Health Service in England. PCTs commission primary, community and secondary care from providers. Page 8

10 system. It ensures accessibility of treatment services for all people in need, in particular those in deprived areas who are most likely to need them. Access The fact that the NTA was set up as a special health authority within the NHS, was recognition that substance abuse treatment cannot be seen in isolation from the general provision of a comprehensive service that is free at the point of use, and based on need, not ability to pay. This made treatment services available to everyone in need and investments over the last decade increased the capacity substantially so that people can access services easily and quickly whenever they need. Treatment services are generally accessed directly by substance misusers voluntarily approaching a treatment provider. Beside this, access can be ensured through referrals from GPs and primary care practices that have identified the need for treatment at regular health-check visits. Also, about a quarter of drug users in treatment are referred through the criminal justice system. This is an indication of the effective multi-agency approach to treatment delivery in the UK and the successful integration of the substance abuse healthcare services with general healthcare and the criminal justice system, vision which the US looks to be moving towards. Balanced treatment based on individual needs - England has a balanced treatment system which ranges from needle exchange programmes and advice to those who have yet to enter treatment through to complex treatment interventions like inpatient detoxification and residential rehabilitation. There are three main components which contribute towards this balanced treatment system: medical, talking therapies and social/peer support which, when used together, can enable people to recover. To be effective, treatment is suited to the needs of each individual as there is no treatment programme that fits all individuals. Treatment in the criminal justice system As mentioned already, since the mid-1990s, the main focus of British substance abuse strategies has been to reduce drug-related crime through treatment and other related initiatives. Over the years, the goal of treatment has shifted from reduction of drug and alcohol use to reduction of crime, resulting in the treatment system being more closely aligned with the criminal justice system. As crime was seen to be the major harm caused by drug dependence increased effort was put on creating mechanisms in the criminal justice system that can direct offenders into treatment. Today, about a quarter of all identified problem drug users in England are treated in prisons 15. Having recognised that treatment in criminal justice can be effective, the government has made substantial investments trying to bring treatment for drug offenders at every stage in the criminal justice system. Today, there are a range of referral paths to structured treatment within the criminal justice system, both community and prison-based. A variety of programmes have been started for this purpose, but the major initiatives include the development of the Drug Interventions Programme (DIP) and Drug Rehabilitation Requirement (DRR) in the community, and the Integrated Drug Treatment System (IDTS) in prison. Drug Rehabilitation Requirements (DRRs) attached to community sentences offer courts - through offender management, treatment and testing a robust alternative option to incarceration, for tackling drug misuse and offending in the community. However, latest available studies (2009) show that, DIP is the most successful referral path among all criminal justice based initiatives with about half of all referrals in the criminal justice being made Page 9

11 through DIP arrest referrals 16. There is also evidence that the overall volume of offending is much lower between offenders following DIP identification and treatment. This is probably the most comprehensive programme as it works across the full range of criminal justice settings (i.e. police, courts, probation and prisons) and links with the drug treatment system to identify drug misusing offenders who are not in treatment. Although there are no statistics on the impact of the recently established Integrated Drug Treatment System (IDTS) programmes in prisons, early evidence suggests that they are becoming the primary drug treatment regime in prisons already engaging significant number of drug users in structured treatment. They improve the volume and quality of drug treatment with a particular emphasis on the first 28 days in custody and provide better integration with community services to ensure continuity of care for drug offenders. The box below describes the most common drug treatment programmes in the criminal justice system in England. Most of them are similar to the initiatives in the US, if not the same (such as the establishment of Dedicated Drug Courts). Although they might have different names and delivery approaches from those in the US, the goals and principles of their operation remain same between both countries: delivering treatment to offenders at every stage of the criminal justice system through collaborative, local partnerships-based approaches and ensuring continuity of care between custody and community. What the UK seems to be more focused on, is the evolving integration of all these approaches in the criminal justice system and the established links between Primary Healthcare practices and drug services both in prisons and community. Box 1. Drug Programmes in the Criminal Justice System Prison-based initiatives INTEGRATED DRUG TREATMENT SYSTEM (IDTS) This is structured, evidence-based treatment regime, recently introduced to all prisons in England. This programme provides a wider range of more intensive drug treatment services, including maintenance prescribing to prisoners. The aim is to ensure greater integration of treatment generally, with an emphasis on clinicians and drugs workers creating multidisciplinary teams. COUNSELLING, ASSESSMENT, REFERRAL, ADVICE AND THROUGHCARE SERVICE (CARATS) CARATS teams are drug workers who provide specialist services, including case management and advice, for problem drug users inside prisons, following assessment. CARATS drug workers also deliver psychosocial treatments, on a one-to-one and group basis, and are responsible for running specific aspects of the IDTS treatment package. Community-based initiatives DRUG INTERVENTIONS PROGRAMME (DIP) The government introduced DIP in 2003 as a key part of its strategy for tackling drugs and reducing crime via the criminal justice system. It brings together a range of agencies including the police, courts, prison and probation services, treatment providers, government departments and Drug Action Teams (DATs). They work together to provide tailored treatment for offenders with drug problems, and ensure those who are reluctant to take responsibility for their behaviour face tough choices. A number of initiatives operate under DIP, including Test on Arrest, Required Assessment and Restrictions on Bail. Test on Arrest Any adult arrested for a specific offence, such as robbery or burglary, in a DIP high-crime area can be 16 National Treatment Agency (NTA) 2009, Breaking the Link: The Role of Drug Treatment in tackling crime, Page 10

12 tested for heroin and cocaine. It s a way of identifying offenders with problem drug use at an early stage, regardless of whether they are charged. Data shows around a third test positive for Class A drugs. Required Assessment When an adult tests positive for heroin or cocaine the police can require them to attend up to two assessments with a drug worker; failing to attend and remain at the assessment is a criminal offence. Restrictions on Bail Offenders who test positive for drugs such as heroin, crack and cocaine may be denied bail unless they agree to have relevant treatment. CRIMINAL JUSTICE INTEGRATED TEAMS (CJITs) Based in the community, and working in police custody suites and courts, CJITs provide a gateway into treatment for offenders. They case-manage offenders, coordinating the response from different agencies, such as the police and prison service. Judges and magistrates take CJIT assessments of drug-misusing offenders into consideration when making bail and sentencing decisions. DRUG REHABILITATION REQUIREMENT (DRR) These are part of a community sentence. They are a key way for offenders to address problem drug use and how it affects them and others through the impact on crime and health. A DRR lasts between six months and three years, and gets offenders to identify what they must do to stop offending and using drugs and to develop their awareness of the victims of crime. The number of DRR orders has increased 4 times since introduction, while completion rates have improved to 43% in DRUG COURTS These courts are specifically set up to deal with drug-involved offenders, who are sentenced to Drug Rehabilitation Requirements. They are based on the US drug court model, and have specially trained magistrates and judges, who are intended to provide continuity of contact with the offender through the sentencing and review process. Other Initiatives PROLIFIC AND OTHER PRIORITY OFFENDER (PPO) SCHEME These programmes manage offenders who are identified as committing a disproportionate amount of crime and harm in their local communities. They usually consist of three strands: deter young offenders; catch and convict; and rehabilitate and resettle. Given the benefits to be gained from ensuring offenders receive effective treatment for problem drug use, the government also made a commitment to tackle drug-related offending through this program by targeting problem drug users, who cause most damage to local communities. INTEGRATED OFFENDER MANAGEMENT (IOM) Integrated Offender Management (IOM) is the overarching framework that allows local and partner agencies to come together to ensure that offenders are managed in a coordinated way. IOM brings under one umbrella DIP and PPO schemes trying to encourage coherent joint working across partnership agencies to ensure that targeted offenders do not fall through the gaps between existing programmes and approaches, and that identified problems are addressed. 17 Ministry of Justice, UK (2008), The National Offender Management Service Drug Strategy , Page 11

13 IT modernisation of substance abuse treatment in the UK As already mentioned, UK has made large investments in advancing the treatment system in last decade. Investments in IT infrastructure, in particular in electronic client information systems have been one of the major ways of improvement of treatment services. Although IT investment decisions were made by commissioned providers themselves, the government focus on improving and standardising the collection of intelligent data has influenced wider adoption of information systems among providers. The result is that the majority of UK treatment providers, in particular larger providers (e.g. Mental Health Trusts and national Voluntary Sector organisations) have already implemented clinical information systems that can collect substance abuse treatment data. Following government reporting requirements for substance abuse treatment services to be submitted electronically to a central national database, support has been provided to treatment agencies and software suppliers by the NTA (National Treatment Agency), to embed substance abuse data collection into their systems or develop such systems from scratch. This has boosted the development and adoption of this type of software in treatment agencies in the last decade so that today electronic collection, processing and exchange of client data, is a commonly accepted practice in the wider treatment system. This has resulted in major benefits for providers bringing improvements both in the quantity and quality of treatment services. Beside this, there are benefits for the government too, as the streamlined electronic collection of real-time data allows for evidence-based, informed policy development and treatment service planning. Although there is no systematic research on national scale about the benefits acquired so far, many treatment providers who have already implemented client information systems have reported significant benefits such as: Successful Multi-agency Working: Client data can be accessed by multiple agencies and users allowing for successful delivery of partnership initiatives Support for Integrated Case Management and Continuity of Care: Client care plans can be shared between all treatment providers involved in treating the client which provides real continuity of care across diverse agencies Privacy and Security of Client Data: Technology used in information systems can provide maximum security of data, protecting the privacy of confidential client information Improved Staff Productivity: Data entry is easy and straightforward and treatment staff can focus on spending time with clients rather than on producing documentation as reports get produced automatically by the system Improved Data Quality and Reporting: Duplication of data is avoided while accuracy is improved; Data is cleansed at the point of entry by case managers rather than retrospectively by IT staff; Reports can be produced automatically and exported to monitoring bodies in predefined formats Real-time Tracking of Client Progress and Outcomes: Information systems can store and provide easy access to all types of client information in real time which helps treatment staff monitor the progress clients are making, get alerts about unmet targets and act upon them Compliance with national standards and regulations: Compliance with national standards and policies is one of the key reasons for implementing information systems; compliance is normally required with national reporting standards as well as privacy, data security and information sharing regulations; many of these couldn t be met without an electronic client records system. Page 12

14 As the summarised framework of the UK substance abuse treatment system below shows, the underlying IT infrastructure is the key enabling factor, supporting seamless delivery of treatment services: Figure 1. UK Substance Abuse Treatment System Framework Access Criminal Justice System Healthcare system Governance Centrallycoordinated: National Treatment Agency (NTA) Locally-owned: Partnership-based approach Prisons Harm reduction programmes (Needle exchange) Talking therapies Community/ Parole & Probation General healthcare practices/gps Balanced treatment approach Specialty treatment agencies Medical programmes Social/peer support Funding Pooled Budget from Central government IT Infrastructure Benefits from substance abuse treatment in the UK Evidence collected over the last decade shows that investment in substance abuse treatment has produced significant benefits for the substance misusers, their family and the community. This investment is cost-effective as treatment is highly effective in reducing damage caused by drug dependence, mostly through its impact on the criminality of patients. After a decade of rapid expansion, the treatment system in the UK is now stable and mature, and treatment services are widely available across the country. This is result of investments that have been focused in three key areas: a) increasing the capacity of the treatment system b) improving efficiency and productivity of providers and c) improving the quality of treatment services. The system infrastructure and connections with primary healthcare and criminal justice are already well-established and have provided the required capacity to enable people to get easy and quick access to treatment for a sufficient period of time necessary to bring substantial health gains. Also, investments in information systems, data collection and standardisation practices have improved the quality of data and speed of processing drug and alcohol users through the system, making staff more productive by focusing on their work rather than on producing documentation. This has resulted in more streamlined provision of treatment services, shorter waiting times and more standardised quality of services among providers. Finally, the better quality of data collected electronically by treatment providers has significantly improved the quality of reporting to central government and has facilitated informed policy-development that relies on real-time evidence. This does not mean that the British treatment system is flawless; there is still room for improvement of the outcomes of treatment services, but the major advancements achieved so far are worth the recognition as they put the Page 13

15 country among the leaders in the world and most importantly in a well-placed position to reach further improvement targets. Box 2. Drug treatment investment benefits in the last decade in the UK Drug treatment delivers value for money for the taxpayer For every 1 that is spent on drug treatment, at least 2.50 is saved in crime and health costs 18. Drug treatment reduces crime and offending behaviour Total number of crimes committed by users almost halved following the start of treatment. Semi-coercive approaches, such as the Drug Interventions Programme (DIP) and community drug treatment orders, produce a quarter of those engaged in treatment and the introduction of DIP is associated with significant reduction in drug-related offending Prison-based substitution treatment prior to release reduces re-offending and re-incarceration Drug treatment has become faster, more accessible and more effective Since 2001, the number of people receiving treatment has more than doubled while the average waiting time for treatment has shrunk from two months to less than a week 19 In 2009 about 75% of all problem drug users identified in England heroin and crack addicts were in treatment. 93% of all adults in treatment in 2009 were effectively engaged (either by having successfully completed a treatment programme or remained in treatment for at least 12 weeks, which is considered the minimum needed to achieve a lasting benefit) 20 The steep and continuing rises in the rates of drug-related deaths that occurred throughout the 1990s have now been halted 21. Drug treatment helps users to recover and reintegrate into society (2009) 22 64% of drug users who had housing problem when entering treatment had it resolved by the time of their review The number of drug users who reported they were in full-time education almost doubled between treatment start and review A significant number of drug users who were not in work at the start of treatment had found employment during their treatment 18 National Treatment Agency (NTA) 2009, The story of Drug Treatment, 19 Ibid. 20 Drugs: protecting families and communities: The 2008 drug strategy, UK 21 Ibid. 18 National Treatment Agency (NTA) 2009, The story of Drug Treatment, 22 National Treatment Agency (NTA), 2010, Drug Treatment in , NTA Annual Report, Page 14

16 Similarities between US and UK substance abuse treatment systems Both United States and UK have some of the largest drug use rates in the world. Although the scale of the substance abuse problem is much bigger in the United States than in the UK (given that US population is 5 times that of UK), both nations have faced similar obstacles and challenges in tackling substance abuse. As result, the two countries have developed remarkably similar principles to guide the provision of treatment services (Figure 2). Figure 2. Historic differences in drug policies are disappearing Overlapping treatment principles US Decriminalisation of drug policy/ move away to a balanced approach Partnerships/multi-agency approach Delivery by local communities Focus on recovery and integrated continuity of care Focus on drug offenders and treatment in criminal justice Reliance on IT (Electronic Client Records) UK Medical, treatmentfocused drug policy/ move away to a balanced approach However, the historic differences in their drug policy approaches (characterised with criminalisation of the US drug users and a smaller focus on treatment) have resulted in a somewhat slower-paced development of the treatment system in the US than that in the UK. The smaller investment-focus on treatment has slowed down the development of personnel, information systems and infrastructure within the US substance abuse treatment system, whereas the significant investments made in this area in the UK have improved the infrastructure substantially and created affordable and easily accessible treatment system over the last decade. Knowing that the basic principles guiding treatment are the same between the two countries, recent efforts for improvement of the US treatment system could benefit significantly from gaining an understanding of the similar developments in the UK. There are three major areas relevant to the US, where the United States could benefit from successful UK experiences: a. The multi-agency approach of service delivery in local communities the governance structure of treatment programmes on local level, managed through local DAT (Drug Action Team) partnerships has ensured collaboration and coordinated delivery of treatment services among all local partners including police, probation, local authorities, NHS and voluntary sector representatives. This partnership approach has been successful in ensuring integrated care management between different providers as local partners can share information about clients subject to client consent. The US government is focused on developing multi-agency approaches to service delivery but currently there are a relatively small number of joint service delivery initiatives between providers from different backgrounds (specialty treatment providers, general healthcare practices, and prison and Page 15

17 community corrections based teams) mainly due to the focus of infrastructure and resource development being elsewhere. In rolling-out such initiatives in future, states and local authorities in the US could find it beneficial to examine multi-agency best practices delivered in UK communities. b. The development of treatment programmes in the criminal justice system the UK substance abuse treatment approach is highly focused on delivering interventions in the criminal justice system. As already explained, a variety of treatment programmes have been operational and continuously improved over the last decade so that today there is a treatment option at every stage of the criminal justice system. The most comprehensive one, the Drug Intervention Programme (DIP), has been most successful in ensuring continuity of care for clients on their journey between custody and community. This relies on seamless provision of case management and effective communication of the right information at the right time to the right people involved in the client s treatment. Although some initiatives are already effective in the US (like the drug courts), further infrastructure improvement will allow for seamless delivery of case management in criminal justice settings. Current initiatives for bringing drug screening tools (SBIRT) and integrated case management models (TASC) in the US criminal justice system could benefit from similar initiatives already effective in the UK. c. The improvement of treatment service delivery through IT UK experiences show that technology has been the key enabler for the incremental and transformational changes facing substance abuse treatment providers. Information technology has evolved to support the delivery of innovative multi-agency care for clients by providing secure way for sharing client confidential information among a variety of agencies. The adoption of multi-agency substance abuse information systems has been one of the key factors behind the long-term success of the Drug Intervention Programme (DIP) and DAT partnerships in the UK. Beside this information systems can support integrated delivery of any other programme related to treatment, such as needle exchange and e-prescriptions. Information systems can also enable the delivery of recovery-oriented treatment models as they provide integrated care management, development of treatment plans and tracking of client s progress for any provider having part in the client s treatment plan. Current performance-based payment models and commissioning of services can also be supported more easily with information systems that can generate accurate outcomes and cost measures. For all of these and many other UK treatment initiatives supported by IT, concerned treatment providers and other domain stakeholders in the US could turn to their UK counterparts as there is an opportunity for highly transferable knowledge to be gained. We believe that strong parallels can be drawn between the treatment systems in the UK and US, and we expect increasing rate of similarities in the way treatment services are provided in the two countries in future as both US and UK develop shared vision of the importance of treatment and the way forward for improvement. Since underlying principles for treatment provision are common, there are opportunities for highly transferable experiences from UK to US forthcoming efforts which can help US realise benefits faster and at lower costs as it moves to its vision for transformed, integrated and more cost-effective substance abuse treatment system. Page 16

18 Mi-Case has extensive experience supporting stakeholders in the substance abuse treatment system in the UK, from a range of individual treatment providers to multi-agency partnerships established across the UK healthcare and criminal justice systems. Working directly with treatment providers, Business & Decision has developed a leading, comprehensive multi-agency case management solution to assist the operation and collaboration among partners who provide joined delivery of treatment services in custody and community treatment environments, allowing them to share key client information and ensure client continuity of care. For almost a decade, Mi-Case has been a trusted partner of choice for numerous treatment providers delivering innovative solutions that improve the quality of treatment and help agencies to meet the challenges posed by emerging government requirements. Page 17

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