Recovery and the direction of NHS drug and alcohol services free of substances at the point of delivery

Transcription

1 Recovery and the direction of NHS drug and alcohol services free of substances at the point of delivery Simon Morton Pennine Care NHS Foundation Trust Tameside and Glossop Drug and Alcohol Services

2 Some current research aspirations The Medical Research Council (MRC) is leading a strategy for addiction and substance misuse research Thematic categories for research Cause: aetiology and natural life-course Harm: biological and social prevalence / incidence data Alcohol: harm, new treatments, evaluation Treatment: new therapies, interventions The overall budget for this initiative is 6.5 million made available by the MRC and the ESRC. Public Engagement On 21 January 2010, the British Academy hosted a public engagement event in partnership with the MRC. Addiction research: the next steps The event was chaired by Sir Michael Marmot, and the panel of speakers, including Professor David Leon Three addiction research cluster leaders - Dr Tim Millar, Professor Colin Drummond and Professor David Nutt - presented an overview of the strategy and details of recent results and proposed research Stakeholders include: Academic community, Advisory Council on the Misuse of Drugs (ACMD), Department of Health, Economic and Social Research Council (ESRC), National Institute for Health Research (NIHR), Home Office, National Treatment Agency (NTA), Responsibility in Gambling Trust (RIGT), Various third-sector organisations

3 Direction of orientation Of the local treatment system e.g. NW NTA Recovery Oriented Integrated System (ROIS) Reviewing all existing patients to ensure they are working to achieve abstinence from problem drugs Ensuring treatment programmes are dynamic and support recovery, with the exit visible to patients from the moment they walk through the door Integrating treatment services with other recovery support such as mutual aid groups, employment services and housing agencies

4 Measurement in the ROIS: ndtms J Measuring recovery by assessing and tracking improvements in severity, complexity, and recovery capital, then using this information to tailor interventions and support that boost an individual's chances of recovering and promote progress towards that goal? Pharmacological intervention Assessment & stabilisation Psychosocial sub-intervention Motivational interventions Recovery support sub-intervention Peer support involvement Maintenance Contingency management Facilitated access to mutual aid Withdrawal Family and social network interventions Family support Cognitive and behavioural based relapse prevention interventions (substance misuse focused) Evidence-based psychological interventions for coexisting mental health problems Psychodynamic therapy (substance use focused) 12-step work Counselling BACP Accredited Other Parenting support Housing support Employment support Education & training support Supported work projects Recovery check-ups Evidence-based psychosocial interventions to support substance misuse relapse prevention Evidence-based mental health focused psychosocial interventions to support continued recovery Complementary therapies Other

5 Direction of orientation Of service delivery e.g. Scottish Recovery Indicator 1. Beyond basic needs 2. Personalised services and choice 3. Strengths based approach 4. Access to a comprehensive service 5. Service user involvement / participation 6. Social inclusion and community integration 7. Self-direction and personal control 8. Practitioner / service recovery focus

6 Direction of orientation Of practice e.g. The NHS 10 Essential Shared Capabilities 1. Working in Partnership 2. Respecting Diversity 3. Practising Ethically 4. Challenging Inequality 5. Promoting Recovery 6. Identifying People s Needs and Strengths 7. Providing Service User Centred Care 8. Making a Difference 9. Promoting Safety and Positive Risk Taking 10. Continuing Development and Learning

7 Direction of orientation Of personal recovery orientation e.g. abstinence / medication-assisted

8 Recovery some questions Is recovery to be defined primarily in terms of sustained abstinence? Or can recovery be understood in terms of quality of life markers? If so, how do we measure quality of life? How do we measure recovery capital? What is the relationship between abstinence and quality of life, abstinence and recovery capital? Does quality of life satisfaction and recovery capital predict or determine future recovery? How do official measurements of recovery (free from drug(s) of dependence; reduced reoffending or continued non-offending; in employment; improved health and well-being) fit with current clinical assessment measures, and/or research markers? How do we research peer and social networks? And, if you can you be in recovery if you say you are, how do you research that?

9 Recovery Capital The sum total of internal and external resources that can be mobilised to initiate and sustain long-term addiction recovery. This can span: Traits and attitudes (hope, determination, and confidence) Resources (clothing, food, money, and shelter) Relationships (social connections with conventional society, and spiritual connections to sources of power outside the self). (1) Mike Ashton

10 Quality of life Physical health Activities of daily living Dependence on medicinal substances and medical aids Energy and fatigue Mobility Pain and discomfort Sleep and rest Work Capacity Psychological health Bodily image and appearance Negative feelings Positive feelings Self-esteem Spirituality / Religion / Personal beliefs Thinking, learning, memory and concentration WHO Brief Quality of Life Assessment (2) Social relationships Personal relationships Social support Sexual activity Environment Financial resources Freedom, physical safety and security Health and social care: accessibility and quality Home environment Opportunities for acquiring new information and skills Participation in and opportunities for recreation / leisure activities Physical environment (pollution / noise / traffic / climate) Transport

11 What we know about treatment Methadone maintenance treatment (MMT) produces a range of improved outcomes for heroin dependent individuals (3. 4.) MMT creates the preconditions for a good quality of life, but - at the same time - stigma, the requirements of the treatment programme, and the effects of the medication, limit its achievement (5. 6.) MMT is associated with lower rates of sustained abstinence than those produced by abstinence-oriented interventions, arguably not by much though (7) Adding psychosocial therapies (PSIs) to MMT may make little or no difference to retention or substance use (8) For alcohol, treatment effectiveness may be as much about how treatment is delivered as it is about what is delivered, though cognitive behavioural approaches offer the best chances of success (9) For cocaine/crack problems, any bona fide counselling or therapeutic approach helps some people some of the time, and often helps many people much of the time; though severe cases may need continuing support and residential care (10) Psychosocial adjuncts to pharmacological detoxification treatments improve completion rates and reduce opiate use during and after treatment (8) Many people (60%) completing addiction treatment resume drug and/or alcohol use in the year following treatment ( )

12 What do we know about recovery? Natural recovery or self-change is a well known route to recovery (13) Sustained recovery is the norm, and the majority of treatment seekers are abstinent at 12 years (14) The majority of people, including dependent drinkers, move into and out of different patterns of drinking without recourse to professional treatment. The time to recover and the pathways involved are unique to the individual (9) Individuals with skills and abilities and those who can rely on social networks have greater likelihood of achieving and sustaining abstinence (15) Having 2 or more predictive factors (finding non pharmacological substitute, compulsory supervision, immediate negative consequence for relapse, new relationship, and involvement in spiritual programmes) suggests an improved likelihood of still being abstinent 5 years later (16) Mutual support helps sustain treatment gains ( ) Unassisted or natural recovery is often mediated through self-help, family and friends, and mutual aid groups. (20)

13 Relationships What is the relationship between treatment and recovery? What is the relationship between treatment research and recovery research? Alexandre B. Laudet, at the US Center for the Study of Addictions and Recovery at National Development and Research Institutes, Inc. (NDRI) David Best, Associate Professor of Addiction Studies at Monash University and Turning Point Alcohol and Drug Centre, Australia

14 What does recovery mean to you? Lessons from the recovery experience for research and practice (21) Laudet, 2007 AIM To examine recovery definitions and experiences among persons who selfidentify as "in recovery." Two questions are addressed: (a) Does recovery require total abstinence from all drugs and alcohol? (b) Is recovery defined solely in terms of substance use or does it extend to other areas of functioning as well? DESIGN AND METHODS Inner-city residents with resolved dependence to crack or heroin were interviewed yearly three times (N = 289). DISCUSSION Most defined recovery as total abstinence. However, recovery goes well beyond abstinence; it is experienced as a bountiful "new life," an ongoing process of growth, self-change, and reclaiming the self. Implications for clinical and assessment practice are discussed, including the need to effect paradigmatic shifts from pathology to wellness and from acute to continuing models.

15 Breaking the habit: a retrospective analysis of desistance factors among formerly problematic heroin users (22) Best et al, 2008 AIM To examine heroin careers among former users to assess desistance factors and explanations for sustained abstinence. DESIGN AND METHODS The study surveyed 107 former problematic heroin users who had achieved long-term abstinence about their experiences of achieving and sustaining abstinence. The cohort was recruited opportunistically from three sources, drawing heavily on former users working in the addictions field. DISCUSSION Participants quoted both social network factors (moving away from drug-using friends and support from non-using friends) and practical factors (accommodation and employment) as well as religious or spiritual factors as key desistance factors. Treatment was not mentioned widely either in achieving or sustaining abstinence, in contrast to 12-Step, which was endorsed widely.

16 Don't wanna go through that madness no more: Quality of life satisfaction as predictor of sustained remission from illicit drug misuse (23) Laudet et al, 2009 AIM This exploratory study tests the hypotheses that quality of life satisfaction prospectively predicts sustained remission, and that motivational constructs mediate the association. DESIGN AND METHODS Inner city residents (N = 289, 53.6% male, mean age 43) remitting from chronic and severe histories of dependence to crack and/or heroin were interviewed three times at yearly interval beginning in April DISCUSSION Baseline life satisfaction predicted remission status one and two years later and the association was partially mediated by motivation (commitment to abstinence) although the indirect effect did not reach statistical significance. Suggestions for future studies are discussed including the need to embrace QOL as a bona fide clinical outcome and to use comprehensive standardized QOL measures that speak to individual dimensions of functioning. Implications are noted, especially the need for the addiction field to continue moving away from the pathologyfocused model of care toward a broader model that embraces multiple dimensions of positive health as a key outcomes.

17 Mapping the recovery stories of drinkers and drug users in Glasgow: quality of life and its associations with measures of recovery capital (24) Best et al, 2011 AIMS To investigate what 'recovery' means for those who describe themselves as in alcohol or drug recovery. DESIGN AND METHODS The project recruited 205 people (107 in alcohol and 98 in heroin recovery) who reported a lifetime dependence on alcohol and/or heroin; had not used their primary substance in the last year and perceived themselves to be either recovered or in recovery. RESULTS Longer time since last use of alcohol or heroin was associated with better quality of life. Greater engagement in meaningful activities was associated with better functioning, and was associated with quality of life, followed by number of peers in recovery in the social network. Heroin users in abstinent recovery generally reported better functioning than those in maintained recovery. CONCLUSIONS Recovery experiences vary widely, but better functioning is typically reported after longer periods of abstinence, and is associated with supportive peer groups and more engagement in meaningful activities, and supports models promoting the development of peer networks immersed in local communities.

18 Treatment research Research thus far has largely focussed on addiction cohorts: - on substance use and related negative consequences (crime, infectious disease) - on treatment / service delivery as a path out of addiction - on cessation of substance use and initiation of change process only in relatively short term studies

19 Recovery research Research should focus: On quality of life and recovery capital On developing measures of recovery to track change over time and examine how these changes are facilitated / hindered by individual s psychosocial context and by services On adopting a developmental recovery career approach to map the full recovery course, its patterns and determinants i.e. LONG- TERM studies On identifying and considering the many pathways to recovery, and recruit accordingly (not just treatment samples)

20 You need perspective to focus Use a telescope, not a microscope George Vaillant

21 References 1. Mike Ashton (2009). Available at: 2. WHO Quality of Life-BREF (WHOQOL-BREF). Available at: 3. Methadone Maintenance Treatment and Other Opioid Replacement Therapies. J. Ward, Richard P. Mattick, Wayne Hall Pharmacotherapies for the treatment of opioid dependence: efficacy, cost-effectiveness and implementation guidelines. Mattick R.P., Ali R, Lintzeris N. Informa Healthcare, A good quality of life under the influence of methadone: a qualitative study among opiate-dependent individuals. De Maeyer J., Vanderplasschen W., Camfield L. et al. International Journal of Nursing Studies: 2011, 48, p Lloyd, C. (2010), Sinning and sinned against: the stigmatisation of problem drug users, University of York, UK. 7. NTORS after five years (National Treatment Outcome Research Study): Changes in substance use, health and criminal behaviour in the five years after intake. Michael Gossop, John Marsden and Duncan Stewart (National Addiction Centre) Psychosocial combined with agonist maintenance treatments versus agonist maintenance treatments alone for treatment of opioid dependence. Amato L., Minozzi S., Davoli M. et al. Cochrane Database of Systematic Reviews: 2011, 10, Art. No.: CD Review of the Effectiveness of Treatment for Alcohol Problems. Duncan Raistrick, Nick Heather and Christine Godfrey. NTA. November No reason for pessimism over treating cocaine problems. Mike Ashton. Drug and Alcohol Findings, Available at: Gossop, M. et al. Factors associated with abstinence, lapse or relapse to heroin use after residential treatment: protective effect of coping responses. Addiction, 97, Outpatient versus inpatient opioid detoxification: a randomized controlled trial. Day E., Strang J. Journal of Substance Abuse Treatment: 2011, 40, p

22 References 13. Natural history of substance-related problems Ed Day, David Best. Psychiatry Volume 6, Issue 1, Pages 12-15, January. 14. Addiction careers and the natural history of change. David Best. NTA Cloud, W. & Granfield, R. (2001). Natural recovery from substance dependency: Lessons for treatment providers. Journal of Social Work Practice in the Addictions, 1(1), Addiction Aug;98(8): A 60-year follow-up of alcoholic men. Vaillant GE. 17. Exploring the additive effects of drug misuse treatment and Twelve-Step involvement: does Twelve-Step ideology matter? Fiorentine R, Hillhouse MP. Subst Use Misuse Feb;35(3): After drug treatment: are 12-step programs effective in maintaining abstinence? Fiorentine R. Am J Drug Alcohol Abuse Feb;25(1): Drug treatment and 12-step program participation: the additive effects of integrated recovery activities. Fiorentine R. Hillhouse MP. J Subst Abuse Treat Jan;18(1): Peer-based addiction recovery support: history, theory, practice, and scientific evaluation. White W.L. Chicago, IL: Great Lakes Addiction Technology Transfer Center and Philadelphia Department of Behavioral Health and Mental Retardation Services, What does recovery mean to you? Lessons from the recovery experience for research and practice. Laudet AB. J Subst Abuse Treat Oct;33(3): Breaking the habit: a retrospective analysis of desistance factors among formerly problematic heroin users. Best DW, Ghufran S, Day E, Ray R, Loaring J. Drug Alcohol Rev Nov;27(6): Don't wanna go through that madness no more: quality of life satisfaction as predictor of sustained remission from illicit drug misuse.laudet AB, Becker JB, White WL. Subst Use Misuse. 2009;44(2): Mapping the recovery stories of drinkers and drug users in Glasgow: quality of life and its associations with measures of recovery capital. Best D, Gow J, Knox T, Taylor A, Groshkova T, White W. Drug Alcohol Rev May;31(3): doi: /j x. Epub 2011 May 27.