How can opioid substitution therapy (and drug treatment and recovery systems) be optimised to maximise recovery outcomes for service users?

Transcription

1 ACMD Advisry Cuncil n the Misuse f Drugs Hw can piid substitutin therapy (and drug treatment and recvery systems) be ptimised t maximise recvery utcmes fr service users? Octber 2015 ACMD RECOVERY COMMITTEE OPTIMISING OST REPORT 1

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3 ACMD Advisry Cuncil n the Misuse f Drugs Rt. Hn. Mike Penning MP Minister fr Plicing, Crime and Criminal Justice Hme Office 2 Marsham Street Lndn SW1P 4DF Chair: Prfessr Les Iversen Secretary: Zahi Sulaiman 1 st Flr (NE), Peel Building 2 Marsham Street Lndn SW1P 4DF Tel: ACMD@hmeffice.gsi.gv.uk Dear Minister, 23 Octber 2015 RE: Hw can Opiid Substitutin Therapy (and drug treatment and recvery systems) be ptimised t maximise recvery utcmes fr service users? In Nvember 2014, the Advisry Cuncil n the Misuse f Drugs (ACMD) published its first reprt in respnse t a cmmissin frm the Inter-Ministerial Grup n Drugs. This cmmissin was explring the questin f whether r nt peple in treatment are maintained n piid substitutin therapy fr lnger than is necessary r desirable. I am pleased t enclse the secnd and cncluding reprt f this cmmissin frm the ACMD s Recvery Cmmittee, which examines the questin: Hw can cntinuing piid substitutin therapy be ptimised in rder t maximise utcmes fr service users? This reprt als reflects the Recvery Cmmittee s cnsideratins n additinal questins psed by Gvernment: Hw can lw expectatins f achieving recvery utcmes be tackled? Hw can psychscial and recvery supprt be imprved? Hw can misuse and diversin f OST prescriptins including illicit herin use n tp f prescriptins be addressed? a a The ACMD is currently undertaking a separate inquiry n the diversin and illicit supply f medicines ACMD RECOVERY COMMITTEE OPTIMISING OST REPORT 3

4 Whether a mandatry review f treatment is required if OST is nt wrking? Is it pssible t identify which herin users in treatment are mre likely t achieve recvery utcmes? Hw culd resurces be priritised t achieve mre recvery utcmes (particularly vercming dependence), emplyment and scial reintegratin? In this reprt, we have reviewed the evidence available; prvided detailed cnclusins reached based n the evidence; and have detailed bespke recmmendatins fr Gvernment, Lcal Authrity Cmmissiners and Drug treatment services and staff. Yurs sincerely, Prfessr Les Iversen Annette Dale-Perera Richard Phillips (ACMD Chair) (C-Chair f the (C-Chair f the Recvery Cmmittee) Recvery Cmmittee) CC: Rt Hn Theresa May MP, Hme Secretary Rt Hn Jeremy Hunt MP, Secretary f State fr Health Jane Ellisn MP, Parliamentary Under Secretary f State fr Public Health ACMD RECOVERY COMMITTEE OPTIMISING OST REPORT 4

5 Cntents 1. Intrductin The cmmissin Hw the Advisry Cuncil n the Misuse f Drugs Recvery Cmmittee has gathered evidence t answer this questin Answering the questins Drug strategy recvery aspiratins versus evidence n recvery utcmes fr herin users What enables recvery utcmes in different dmains t be achieved? Optimising utcmes fr herin users: key factrs driving utcmes The quality and effectiveness f the lcal treatment and recvery service including management and staff cmpetence Opiid substitutin therapy Opiid substitutin therapy service users rating f the quality f drug treatment and recvery services in England OST: evidence-based practice Dse OST medicatin type Supervised cnsumptin Recvery keywrk, care planning and review Psychscial interventins Dse f interventin: Hw much is enugh? Types f psychscial interventins Staff attitude and cmpetence Management and culture f piid substitutin therapy treatment and recvery services in England Lcally cmmissined treatment and recvery system including piid substitutin therapy Wider lcal systems Mental health Physical health Educatin, training and emplyment Husing Natinal framewrks, guidelines, enabling bdies and levers t maximise recvery utcmes guidance and delivery assurance Service user factrs Evidence that peple with herin dependence are mre likely t achieve recvery utcmes Segmenting the herin-dependent ppulatin Cnclusins Recmmendatins ACMD RECOVERY COMMITTEE OPTIMISING OST REPORT 5

6 1. INTRODUCTION 1.1. The cmmissin The Inter-ministerial Grup (IMG) n Drugs psed questins t the Advisry Cuncil n the Misuse f Drugs (ACMD) Recvery Cmmittee (RC) fllwing nging cncerns abut the perceived limited prgress f herin users in OST twards achieving recvery utcmes especially vercming dependence n piids. The fllwing questins were psed: Cnsider the available evidence n whether r nt peple in treatment are maintained n piid substitutin therapy fr lnger than is necessary r desirable. Des the evidence supprt the case fr time limiting piid substitutin therapy? If s what wuld a suitable time perid be and what wuld be the risks and benefits? If nt, hw can piid substitutin therapy be ptimised t maximise utcmes fr service users? The ACMD has answered these questins in tw parts. The first answer pertaining t whether evidence supprts the case fr time limiting OST was published in Nvember The verall cnclusin f this reprt was that the evidence strngly suggested that time limiting OST: wuld result in the majrity relapsing int herin use; may have significant unintended cnsequences including increasing: drug driven crime; herin verdse deaths; and, the spread f sme bld-brne viruses (including hepatitis and HIV); and, may nt be able t be implemented due t medic-legal challenges. This reprt nted that OST was a helpful platfrm fr herin users twards recvery but, withut psychscial and recvery interventins, limited recvery utcmes were likely. The ACMD als stated that it whlly supprted the natinal drug strategy push t achieve mre recvery utcmes and imprve the quality f drug treatment. This reprt seeks t answer the secnd part f the IMG questins: Hw can OST be ptimised t maximise utcmes fr service users? In additin, the Department fr Wrk and Pensins Minister requested that the ACMD RC cnsiders a number f issues including: hw t tackle lw expectatins f achieving recvery utcmes; hw t imprve psychscial and recvery supprt; hw t address misuse and diversin f OST prescriptins including illicit herin use n tp f prescriptins ; and, whether a mandatry review f treatment is required if OST is nt wrking. Furthermre, fllwing a presentatin f initial findings t the IMG in February 2015, the ACMD RC was als asked t: lk at whether it was pssible t identify which herin users in treatment were mre likely t achieve recvery utcmes; and, advise n hw resurces culd be priritised t achieve mre recvery utcmes (particularly vercming dependence), emplyment and scial reintegratin Hw the Advisry Cuncil n the Misuse f Drugs Recvery Cmmittee has gathered evidence t answer this questin In rder t answer the questins psed, ACMD RC has undertaken further literature reviews, and heard and received evidence n this tpic, including evidence frm: ACMD RECOVERY COMMITTEE OPTIMISING OST REPORT 6

7 drug treatment cmmissiners and prviders; Public Health England; the Centre fr Scial Justice; the University f Manchester; the University f Sheffield; and experts by experience including a natinal survey f service user representatives in England. 2. ANSWERING THE QUESTIONS 2.1. Drug strategy recvery aspiratins versus evidence n recvery utcmes fr herin users In England the drug strategy in 2010, Building recvery in cmmunities recgnised the investment made in drug treatment ver the previus decade and the health gains accrued. Hwever, it als expressed a need t create systems that had mre ambitin t enable thse with alchl and drug dependence t vercme dependence, becme abstinent and achieve ther recvery utcmes. As previusly stated, the Advisry Cuncil n the Misuse f Drugs (ACMD) Recvery Cmmittee (RC) whlly supprts the aspiratins utlined in the drug strategy and wishes t prvide evidence-based advice n hw t enable mre peple t be able t vercme substance dependence and achieve a range f recvery utcmes. The ACMD RC s secnd reprt What recvery utcmes des the evidence tell us we can expect 2 fund that ppulatin studies suggested that mst peple d vercme a perid f substance dependence in their lifetime but sme grups have a greater prbability f vercming dependence and attaining ther recvery utcmes. Evidence was utlined that suggested that thse with herin dependence had prer utcmes than ther grups and that herin dependence was assciated with significant levels f mrtality and mrbidity. The reprt cncluded that whilst there was reasn fr ptimism abut recvery frm dependence, ptimism needed t be tempered with reality. Evidence shws that thse with herin dependence had a greater likelihd f having life prblems prir t dependence than thse with dependence n alchl r ther drugs. A herin-using lifestyle was assciated with significant cllateral damage including high rates f premature death; fr survivrs, physical and mental health prblems, criminal recrds, unemplyment, pr husing, damaged relatinships were likely. Therefre recvery is a highly ambitius gal fr thse with herin dependence. It is asking individuals nt nly t vercme dependence but als t achieve psitive utcmes in health, scial and ecnmic functining that sme have never previusly had all while als trying t manage the cnsequences f significant cllateral damage. This reprt recmmended that a lng-term r extensive apprach is required that supprts the prcess f a radical shift in lifestyle with the UK ppulatin f ageing herin users being prvided supprt acrss a range f utcme dmains fr a number f years. This may include drug treatment, but als mutual aid and wider scial, cultural and ecnmic supprt t enable the recvery jurneys f individuals. It recgnised that extended access t drug treatment, healthcare and supprt may be required fr thse with severe dependence t manage their lives and minimise the ptential cllateral damage f active herin dependence n themselves and thers What enables recvery utcmes in different dmains t be achieved? Accrding t UK clinical guidelines piid substitutin therapy (OST) is designed t: reduce r prevent withdrawals that typically lead t further use f illicit herin; ACMD RECOVERY COMMITTEE OPTIMISING OST REPORT 7

8 prvide an pprtunity t stabilise drug intake and lifestyle while breaking with illicit drug use and assciated unhealthy risky behaviurs (including injecting); prmte a prcess f change in drug taking and risk behaviurs; and, help t maintain cntact and ffer an pprtunity fr therapeutic wrk with a patient r client. There is internatinal cnsensus, and a strng evidence base, supprting the effectiveness f OST t reduce and stp herin use, reduce drug injecting and related bld-brne viruses and reduce drug-driven crime. UK guidelines acknwledge that there is a hierarchy f gals f drug treatment frm reducing drug-related prblems t abstinence, and that treatment gals shuld depend n the mtivatin and circumstances f each individual. These guidelines recgnise that sme peple may be able t cmmit t a determined effrt t becme abstinent while thers may be unable r unwilling t d s, but may be able t make changes such as reducing risk behaviurs. OST is a platfrm t vercme herin dependency and achieve recvery. Hwever, it is critical t recgnise that the prvisin f OST medicatin in itself will nt enable an individual t achieve a full range f recvery utcmes. ACMD wish t pint ut that recvery-rientated piid substitutin drug treatment can help herin users quit herin use, achieve a range f psitive recvery utcmes and prtect against drug-related death and crime while in treatment. Hwever, it is nt the nly part f a jurney fr thse wh vercme piid dependence and abstinence pathways and lng-term recvery supprt are als required. Figure 1: Recvery dmains Figure 1 shws the full range f recvery dmains that may require interventins r resurces during the prcess f recvery. OST medicatin alne is nly designed t impact n a limited number f recvery dmains including drug use, reducing drug driven crime, and preventing health issues including the spread f bld-brne viruses. Services users n OST can achieve medicatin-assisted recvery (MAR) invlving cessatin f herin use, imprved health and well-being and being a participating member f sciety with the crrect supprt. Hwever, vercming piid dependence nrmally requires the service user t fllw an abstinence pathway after MAR, including detxificatin and nging recvery supprt. Evidence suggests that the jurney frm MAR t an abstinence pathway and sustained recvery is risky in that it ften results in lapse r relapse. 3 Thse with recvery assets and nging supprt are mre likely t achieve sustained recvery 4 and s helping service users t build assets shuld be a cre gal f MAR Optimising utcmes fr herin users: key factrs driving utcmes Evidence indicates that there are a number f key factrs that drive variatins in utcmes fr thse with herin dependence. These can be divided int several areas: ACMD RECOVERY COMMITTEE OPTIMISING OST REPORT 8

9 the quality and effectiveness f the lcal treatment and recvery service including management and staff cmpetence (see sectin 3); the lcal treatment and recvery system, including the cmmissining f the system (see sectin 5); wider lcal cmmunity services and assets t supprt wider recvery utcmes and reintegratin, including emplyment pprtunities and reducing stigma and discriminatin (see sectin 6); natinal framewrks, guidelines, enabling bdies and levers t maximise recvery utcmes (see sectin 7); and Service user factrs - the herin dependent ppulatin themselves (see sectin 8). Each f these areas will be lked at in turn. 3. THE QUALITY AND EFFECTIVENESS OF THE LOCAL TREATMENT AND RECOVERY SERVICE INCLUDING MANAGEMENT AND STAFF COMPETENCE There is strng evidence frm multiple studies that the quality and characteristics f treatment and its management can have as much impact n service user utcmes as the service user characteristics themselves and indeed may accunt fr the mre variance. 5,6,7,8 Gd quality, evidence-based drug treatment can help service users achieve recvery utcmes. Pr quality treatment may nt deliver utcmes and may have a negative impact n recvery utcmes. This sectin lks sequentially at: piid substitutin therapy (OST) treatment; lcal treatment and recvery systems; and the wider lcal system f health, scial care and welfare Opiid substitutin therapy Opiid substitutin therapy service users rating f the quality f drug treatment and recvery services in England The service user survey undertaken fr this reprt prvided an insight int the current quality f OST in England with respndents frm arund 116 ut f 152 lcal authrity areas many f whm were lcal service user representatives f recvery champins invlved in lcal cmmissining r prvisin. Service users were asked t rate the quality f the lcal treatment and recvery system fr thse n OST. Results were as fllws fr the whle sample (current OST user results in brackets). It is striking that thse service users currently in OST rated the quality f OST wrse than ther service user representatives n the fllwing items: recvery care planning; chice f medicatin; dse f medicatin; regular review; psychscial supprt; access t mutual aid; healthcare and help t vlunteer r get a jb. Mental health treatment and help with husing were rated as pr r bad by ver half and almst half f all respndents respectively. Pr r bad Neutral Gd r very Mean (1-3) (4) gd (5-6) Staff delivery f recvery-ptimistic care 25% (25%) 12% (20%) 64% (55%) 4.8 (4.5) Assessment 21% (25%) 11% 16%) 70% (59%) 5 (4.6) Recvery care planning 27% (37%) 15% (19%) 58% (44%) 4.8 (4.2) Regular review 31% (40%) 18% (19%) 52% (42%) 4.5 (4) OST medicatin 26% (37%) 11% (17%) 64% (46%) 4.9 (4.1) OST dse 26% (26%) 11% (10%) 63% (62%) 4.9 (4.9) OST supervised cnsumptin 20% (22%) 18% (25%) 62% (64% 4.9 (4.6) ACMD RECOVERY COMMITTEE OPTIMISING OST REPORT 9

10 Staff challenge use n tp 30% (19%) 14% (17%) 56% (64%) 4.5 (4.7) Psychscial supprt 31% (41%) 13% (10%) 55% (49%) 4.6 (4.1) Access t mutual aid 14% (22%) 8% (8%) 78% (69%) 5.4 (4.8) Healthcare fr drug-related prblems 21% (28%) 10% (13%) 69% (59%) 5 (4.7) Mental health treatment 51% (54%) 13% (12%) 37% (34%) 3.8 (3.7) Help with husing 43% (46%) 15% (18%) 38% (36% 3.9 (3.7) Help t vlunteer r get a jb 25% (36%) 15% (13%) 59% (51%) 4.8 (4.1) Services users were asked t cmment n what they thught were the three mst imprtant things that culd ptimise recvery utcmes fr thse in OST. Respnses fell int three grups: the quality f key wrker and psychscial interventins: mre encuragement t cmplete treatment, rapprt, rather than just discussing methadne, need t be seen mre than nce a mnth, cntinuity f key wrker, keywrkers better educated t the needs f the clients, mre mutual aid that welcmes thse n OST, mre peer supprt and mre access t mental health treatment the types f OST medicatin: mre subutex, mre pathways t abstinence and mre detx and rehab places better access t wider recvery supprt t help thse in OST build assets in relatin t educatin, husing, emplyment, scial and ecnmic needs and cmmunity re-integratin. There were als many cmments that thse in OST felt stigmatised and scapegated and this was felt t hinder recvery OST: evidence-based practice There is strng evidence that several key cmpnents f OST are critical t OST treatment utcmes f stpping injecting and spread f bld-brne viruses, cessatin f herin use, and cessatin f crime Dse There is evidence that receiving an ptimal dse f the substitute piid medicatin is critical t utcmes. A crrect dse is achieved fllwing a titratin perid (methadne ptimal dse is usually between 60 and 120mg and fr buprenrphine between 12 and 16mg, and up t 32mg). 9 There is gd evidence that high dses f methadne and buprenrphine result in less piate use 10 and in a reductin in risk behaviurs. 11,18 There is als evidence that individuals n higher dses are mre likely t achieve abstinence successfully with time. 12 Evidence als suggests that there is substantial variatin in hw individual herin users metablise OST fr a range f reasns including genetic nes. 13 Methadne clearance and therefre ptimal dse is increased substantially by sme medicatins including thse cmmnly t treat TB, HIV and epilepsy. 14 Sme medical cnditins such as liver and renal failure may als affect methadne clearance. Therefre dse titratin needs t be an individualised prcess and the effective dse may be variable. 13 Hwever, there is evidence frm surveys that under-dsing may be a cmmn prblem in England. 15 The fllwing bstacles t ptimal dse prescribing have been fund: Prescriber reluctance including mral and plitical reasns Fear f diversin 16 Service user reluctance based n fears that they will never be able t cme ff drugs and that withdrawals frm OST medicatin will be mre difficult. Patients als cmmnly fear side effects including real effects such as sweating and tth damage frm methadne. Hwever, ther fears such as methadne getting int bnes, are nt real. Other patients have persnal bjectives that may be at dds with recvery, such as a desire t take a lw dse and cntinue t use n tp ACMD RECOVERY COMMITTEE OPTIMISING OST REPORT 10

11 Slw reductin regimes requested by the service user r recmmended by the prescriber that may be, in practice, be lng-term under dsing leading t illicit herin use n tp. Lw (sub-ptimal) dse OST is assciated with mre criminality, mre use n tp and mre drug-related deaths. 17 The ACMD wishes t state that service users shuld receive piid substitutin medicatin dses in line with UK clinical guidelines, and sub-ptimal piid prescribing is unlikely t help service users stp illicit herin use and is assciated with prer utcmes. The ACMD is cncerned that there als needs t be clear cmmunity and in-patient detxificatin regimes and pathways, including psychscial supprt, when the service users are ready and able t cme ff OST OST medicatin type There is evidence that, as with any ther medicatin, nt everyne will respnd effectively t every OST drug (e.g. methadne). NICE 18 fund that methadne and buprenrphine were equally effective, variable dse methadne had higher rates f patient retentin than variable dse buprenrphine. Emerging service user survey evidence indicates that buprenrphine and/r buprenrphine/nalxne may be assciated with reduced rates f cntinued herin use n tp. 19 Injectable OST has als been fund t be effective fr thse wh have repeatedly failed at ral OST medicatin. 20 There is sme evidence that slw release ral mrphine is mre effective fr sme patients. 21 ACMD wishes t restate that chice f OST medicatin is therefre required in every service t ptimise utcmes in OST Supervised cnsumptin Evidence shws that supervised cnsumptin f methadne r buprenrphine can ensure that patients take the dse prescribed. This reduces diversin and can prevent verdse. 22 Althugh supervised cnsumptin can create initial structure, it can als be restricting and prevent a patient frm engaging in recvery activities such as paid wrk, and its impact n treatment effectiveness is nt clear. 23,24 Hwever, UK guidelines are clear that take hme dses shuld nly be given if patients are stable and nt using illicit drugs r excessive alchl, r are suspected f diverting medicatin, r if there are cncerns abut risk t children. 9 ACMD re-iterates that the prvisin f take hme dses shuld be explicitly cntingent n cessatin f herin use n tp as evidenced by regular drug testing r ther means and that cntinued use n tp shuld result in a review and ptimisatin f OST Recvery keywrk, care planning and review NICE guidelines recmmend that individuals in OST receive key wrking, where a therapeutic alliance can be established and in the cntext f the service user having an individual care plan with gals. 25 Furthermre, there is evidence frm large-scale natinal service user surveys that having a recvery care plan that has been recently reviewed, and feeling respected by staff are tw factrs strngly assciated with self-reprted psitive recvery utcmes. 26 There is research evidence that the use f cgnitive mapping techniques is assciated with building psitive therapeutic relatinships and service users invlvement in their recvery planning. There is evidence that cgnitive mapping that utilises bth deficit and asset mapping is assciated with imprved retentin and service user utcmes. 6,7,27 There is evidence that the mtivatinal ability f staff is mre imprtant than the initial mtivatin f service users. 28,29 Recent evidence-based guidelines n recvery-rientated drug treatment advcate that t maximise recvery utcmes, care plans shuld be regularly reviewed in mtivatinal reviews invlving service users. 30 ACMD RECOVERY COMMITTEE OPTIMISING OST REPORT 11

12 The ACMD wishes t re-iterate that OST staff shuld ensure every service user has a recvery care plan with gals that has been c-prduced with the service user. Service users shuld receive regular recvery reviews, with updated plans mdified t meet changing needs Psychscial interventins Dse f interventin: Hw much is enugh? There is evidence frm multiple studies that the greater the therapeutic dse f treatment and recvery interventins, the greater the imprvements in recvery utcmes. The therapeutic dse effect is related t the quality and range f services within a drug prgramme, fr example, cunselling, medical care, emplyment assistance, family therapy, husing. 31 Recent research suggests that OST plus supervised cnsumptin, drug tests three times a week, and crisis interventin can be as effective in terms f reducing substance use, crime and the risk f bld-brne disease, as OST with mre psychscial interventins regardless f whether the patient was under criminal justice supervisin. Hwever, OST with cunselling appeared t enable mre service users t leave OST. 32 There is evidence that herin users in OST utcmes are prgressively better with mre psychscial interventins. McLellan et al cmpared methadne alne with n ther services (MMS) with the standard methadne service (SMS), i.e. methadne plus cunselling, and enhanced methadne services (EMS) with cunselling, n-site medical/ psychiatric access, family therapy and emplyment help. Outcmes including the cessatin f herin use and less use f emergency rms were greater with mre psychscial input. 33 A fllw-up study n cst-effectiveness shwed that the intermediate service with cunselling was the mst cst-effective. 34 Sme studies f ccaine and crack use amngst thse in OST fund that they may require intensive psychscial treatments that target the cnsiderable prblems faced by inner-city piid-addicted individuals. 35 Hwever, there is sme evidence frm the UK that herin users in OST d nt get enugh psychscial interventins t maximise behaviur change and receive recvery supprt. Best et al. fund that n average thse in OST received nly 20 minutes f psychscial supprt per frtnight. 36 Furthermre, the ACMD RC heard evidence that sme peple n OST particularly thse in primary r shared care services are thught t receive very little psychscial supprt and had little expsure t visible recvery r mutual aid. The service user survey cnducted by the ACMD RC fr this reprt indicated that many service users d nt have access t the psychscial interventins they required. This survey fund that nly 22% said that peple n OST get enugh psychscial and recvery supprt with 64% saying they did nt get enugh supprt and 14% saying they did nt knw whether they gt enugh supprt. The ACMD recgnises that there is a lack f evidence n what intensity r dse f psychscial interventins is required by different grups f herin users in England, by whm and at what stage f the recvery prcess. It recmmends that mre research is required in this area. Hwever, the ACMD remains cncerned at the emerging evidence f pr dses f psychscial interventins Types f psychscial interventins There is strng evidence fr the use f cntingency management in reducing ccaine r crack and herin use amng thse in OST. 25,37 There is als striking evidence that treatment f piid-using prfessinals, such as dctrs, has better utcmes and features: OST medicatin; rigrus n-ging mnitring and randm drug testing; and, psychscial supprt. 38 ACMD RECOVERY COMMITTEE OPTIMISING OST REPORT 12

13 These interventins can result in cessatin f herin use. Hwever, t deliver these pwerful techniques, randm drug testing with immediate cntingent rewards are required. There is little evidence that cntingency management has been implemented in the UK despite being advised in NICE and UK clinical guidelines. There is research evidence that family therapy and behaviural cuples therapy (BCT) can imprve utcmes fr herin users and these appraches are recmmended by NICE 25 and UK clinical guidelines. 9 Again the ACMD RC fund n evidence that these appraches have been widely implemented. There is research evidence that service user invlvement in mutual aid (particularly 12-step appraches) 39 is assciated with a higher chance f achieving abstinence and ther recvery utcmes 40 and is recmmended by NICE and UK Clinical Guidelines. 9,25 ACMD received evidence f widespread grwth f mutual aid in England which was encuraging. Hwever, access t sme types f mutual aid fr thse in OST may be limited, which may hinder achievement f utcmes amngst thse in OST. There is mixed evidence abut the impact f ther types f talking therapies and techniques used in cnjunctin with OST. UK Clinical Guidelines recmmend use f a range f techniques. 99 Sme studies fund n difference between thse in OST receiving extra CBT fcusing n their ccaine use, in terms f the reductin in ccaine use. 41 NICE guidelines recmmend cgnitive behaviural therapy is nt used fr the treatment f addictin fr thse n OST but shuld be used fr the treatment f c-mrbid depressin r anxiety. 25 There is sme evidence frm qualitative studies n the benefit f psychscial supprt in OST. The Dutch study by de Maeyer et al. says: A number f participants mentined methadne s limited impact n achieving a meaningful life, stating that they experienced methadne purely as a substitute fr their herin use. They cited the imprtance f psychscial cunselling, alngside their pharmaclgical methadne treatment, t supprt them in achieving a meaningful life. 42 There is als evidence that thse in OST fr lng perids f time, wh have psychlgical distress, withut being able t change their living situatin, experience lw levels f quality f life; having at least ne gd friend and a structured daily activity had a significant, psitive impact n quality f life. 43 There is very strng evidence that prvisin f psychscial treatment, alne, dubles patients' risk f a fatal verdse, cmpared t enrlment in OST. Psychscial treatment is best prvided as an additinal, nt an alternative, cmpnent f the treatment respnse. 44 The ACMD wishes t re-iterate that evidence-based psychscial interventins shuld be prvided systematically t service users in OST, based n need. It is cncerned abut the lack f implementatin f techniques with the best evidence (cntingency management including drug testing, BCT and family therapy) and recmmends that this situatin shuld be rectified. The ACMD welcmes the spread f mutual aid and recmmends facilitated access and mre access fr thse in medicatin-assisted recvery. It als ntes the imprtant rle f CBT t treat mental health prblems in this grup. Tgether with cessatin f illicit herin use (ideally within six mnths), a critical fcus in OST appears t require helping peple t build psitive relatinships and establish meaningful daily activity and reintegrate int the cmmunity Staff attitude and cmpetence There is evidence that staff themselves have a significant impact n service user utcmes. The fllwing staff characteristics have been fund t be assciated with better utcmes fr herin users r thse n OST: Staff (methadne cunsellrs) wh were mre active, diligent and helped patients t anticipate prblems and find slutins. 45 Staff with the ability t frm warm, supprtive relatinships with patients. 46 Methadne maintenance prgramme staff wh were active and experienced, and wh gave mre frequent cunselling sessins, had fewer patients wh were illicitly using crack and herin. 41 ACMD RECOVERY COMMITTEE OPTIMISING OST REPORT 13

14 Several studies have fund that thse patients wh reprted gd relatinships with their dctrs had mre psitive addictin utcmes 47 and greater cessatin f illicit herin use within six mnths. 48 There is evidence that the mtivatinal ability f staff has a greater impact n initial client mtivatin than the initial mtivatin f service users 28,29 There is a lack f UK evidence n what staff team qualificatins and backgrunds are required t maximise recvery utcmes. The ACMD RC ntes that the fllwing prfessins wuld nrmally be required t deliver evidence-based recvery-rientated OST: medical and nursing staff fcused n cmplex addictin needs, health and prescribing; psychlgists t deliver BCT and family therapy, versee cntingency management and deliver CBT fr mental health prblems; experts by experience t deliver mutual aid; key wrkers (with Drug & Alchl Natinal Occupatinal Standards (DANOS) r equivalent cmpetence in substance misuse). Hwever, it is interesting t nte that sme key deficits in the system are the psychlgist-led interventins reflecting a lack f qualified psychlgists in drug treatment services. 4. MANAGEMENT AND CULTURE OF OPIOID SUBSTITUTION THERAPY TREATMENT AND RECOVERY SERVICES IN ENGLAND There is gd evidence that the quality, management and culture f drug treatment prviders has a large impact n service users utcmes and is perhaps a greater influence n recvery utcmes than presenting characteristics f OST service users themselves. There is research evidence that well managed services achieve better utcmes. Evidence frm the US 49 and UK 27 shws that measures f rganisatinal readiness fr change are a better predictr f utcmes than patients self-evaluatin f their readiness fr treatment. Natinal guidance advcates implementatin f recvery rientated drug treatment 30 including a review f lcal services and steps t mdify and change services t ensure a change in culture t a recvery rientatin. The ACMD RC culd nt find evidence n whether this guidance has been implemented and what the impact was. The ACMD RC heard evidence frm Public Health England (PHE) that it had prvided seminars t encurage the adptin f recvery-riented drug treatment (RODT) including data n lcal systems and services and evidence-based prblem slving advice. Hwever, the uptake f these seminars was vluntary and subsequent actin and impact n lcal systems is unknwn. The ACMD RC heard anecdtal evidence n variable lcal appraches and cultures with sme services nt adpting a recvery apprach, thers trying t adpt a recvery apprach and sme cmmissiners reprcuring services in rder t push fr a culture change. Hwever it was difficult t get evidence beynd anecdtes n these trends and their impact and there was a lack f an agreed measure f recvery culture and culture change. Frm the heard evidence the ACMD RC had sme cncerns abut whether there was a default t autmatic OST fr herin users presenting t treatment withut a prper chice f abstinence pathways earlier in treatment jurneys. The grup discussed the difficult chices and decisins between OST pathways that help herin users t stabilise and reduce risk f harms (including verdse death and crime) and abstinence pathways f detxificatin and recvery supprt which are assciated with higher risk r relapse, verdse and subsequent return t drugs and crime. ACMD RECOVERY COMMITTEE OPTIMISING OST REPORT 14

15 The grup was cncerned abut whether there were bth adequate encuragement and supprted pathways t abstinence fr thse n OST, and whether thse n OST were presented these as ptins n a regular basis recgnising that this is nrmally a higher risk pathway. The ACMD recmmends further explratin f this area. There is evidence frm the ACMD RC OST service users survey abut service expectatins and staff cmpetence in recvery-rientated treatment. In the survey service users were asked what utcmes they thught that lcal services expected them t achieve. The results were as fllws fr the whle sample (current OST users in brackets). Arund threequarters (r mre) f the whle sample thught that they were expected t: stp using n tp (76%) stp injecting (74%) stp drug-driven crime (78%) cme ff OST in the future (78%) wrk twards being abstinent frm drugs (78%) imprve their physical health (80%) imprve their mental health (75%) have gd relatinships with family/friends (72%). Just ver half (54%) thught that they were expected t train r vlunteer and a similar prprtin (56%) felt that they were expected t find wrk r cme ff benefits. 5. LOCALLY COMMISSIONED TREATMENT AND RECOVERY SYSTEM INCLUDING OPIOID SUBSTITUTION THERAPY Drug treatment and recvery systems (including piid substitutin therapy (OST)) are delivered in 152 lcalauthrity based systems in England. Evidence suggests that there is cnsiderable variatin in drug treatment and the quality f OST in England. These variatins may have many causes including: different appraches t cmmissining including the frequency f re-prcurement; financial resurces in the lcal system; lcal cmmitment and supprt fr recvery and thse in the prcess f recvery; the quality f treatment including the quality and skills f staff; the culture f the lcal treatment system; the different ppulatins f services users; the availability f mutual aid in the lcality; herin users access t ther services (mental health, husing, scial care, educatin and emplyment, etc.); and, the level f influence r c-prductin that service users have. The ACMD RC was given presentatins f management data frm Public Health England (PHE) that indicated there is a cnsiderable variatin in lcal areas and services n: the numbers in OST, the ppulatin grups in OST, and the impact f service user behaviur and utcmes. ACMD RECOVERY COMMITTEE OPTIMISING OST REPORT 15

16 The last natinal review f OST in England was cnducted in and shwed cnsiderable variatin in the quality f OST in the areas f: cmmissining f prescribing services; assessment and care plans; prescribing practice; safety; and, staff cmpetencies. 50 Significant wrk was subsequently undertaken by natinal and lcal bdies t imprve OST but the ACMD ntes there has nt been anther imprvement review that can benchmark practice and act as a platfrm t drive up quality in line with evidence. The ACMD RC lked fr evidence that there was a balance between medicatin-assisted recvery pathways and abstinence pathways fr thse with herin dependence in lcal areas. There was a lack f evidence n this tpic thugh ther authrs had cmmented n this 51 and it may require explratin. The service user representatives survey cnducted fr this paper indicated that there was a limited chice f treatment and recvery pathways fr herin users in Half (50%) f all respndents (55% f the grup wh were currently in OST) said there was nt enugh chice f treatment pathways in their lcal area; 54% (56% f thse in OST) reprted nt enugh pathways t in-patient detxificatin plus aftercare, and 46% (39% f the grup wh were currently in OST) said there was nt enugh access t cmmunity detxificatin; and 55% (52% f thse in OST) said there was nt enugh access t residential rehabilitatin fr herin users. On a mre psitive nte: 80% (althugh nly 63% f the grup currently in OST) said that there was access t mutual aid; 81% (75% f thse currently in OST) said there is enugh access t OST with methadne; and, 74% (68% f thse in OST) said there was enugh access t OST with buprenrphine. In terms f the impact f cmmissining n recvery utcmes, the ACMD RC will publish a part 1 reprt n The impact f trends in cmmissining and austerity n recvery utcmes in late Early findings frm this reprt are that there is significant churn in drug treatment in England due t frequent re-prcurement f lcal services (every three t five years). Evidence frm a survey f cmmissiners and surveys f prviders 52 indicate this frequency f re-prcurement appears t have a destabilising impact and negative impact n lcal service user recvery utcmes (fr up t tw years) just ne year befre sme re-prcure again. Other negative impacts are nted n: staff mrale and retentin due t staff frequently TUPE d b between prviders; increasing purchase f cheaper mdels with less qualified, less expensive staff; and, prvider management resurces and fcus taken up by tendering when this energy culd be fcused n quality. While sme lcal areas are re-prcuring with explicit aims t imprve lcal services r implement mre recvery-rientated mdels, this is set in the cntext f reducing finances ver the next three years and a b The Transfer f Undertakings (Prtectin f Emplyment) Regulatins 2006 (SI 2006/246) is knwn as TUPE and is the UK s implementatin f the Eurpean Unin Business Transfers Directive. ACMD RECOVERY COMMITTEE OPTIMISING OST REPORT 16

17 sharp in year (2015/16) drp in resurces all frm a platfrm f frequent reductins ver the previus fur t five years. 6. WIDER LOCAL SYSTEMS 6.1. Mental health There is cnsistent evidence f a higher prevalence f mental health prblems including depressin, anxiety, trauma and persnality disrder amngst herin users and thse n OST (especially amng wmen n OST) cmpared with the general ppulatin. 53 Furthermre, there is evidence that thse with mental health prblems are less likely t achieve abstinence and mre likely t relapse in treatment and relapse n release frm prisn. 54 The ACMD RC als received evidence frm service users and service prviders that access t mental health interventins was difficult fr sme f thse n OST as lcal prtcls required them t be drugfree. Service users reprted that untreated mental health issues were a majr barrier t achieving recvery utcmes including emplyment and trying t cme ff OST. The ACMD is cncerned that the lack f access t mental health treatment may be a barrier t service users cming ff OST medicatin and achieving recvery utcmes as a level f well-being may be critical t enable peple t acquire assets such as emplyment and new psitive relatinships Physical health The ACMD RC heard evidence f relatively high levels f physical health c-mrbidity and disability amng thse n OST particularly lder service users and including chrnic bstructive pulmnary disease (COPD) (smking related), hepatitis C and deep vein thrmbsis. Addressing (if pssible) these health needs may be required befre thse n OST culd be expected t achieve ther recvery utcmes such as emplyment. As examples, implementatin f smking cessatin may reduce COPD and the new treatment regimens fr hepatitis C culd result in the vast majrity becming free f the hepatitis C virus. A fcus n addressing physical health needs is f increasing imprtance t the UK ageing chrt n OST. The ACMD RC heard sme evidence f the implementatin f the give ways t well-being mdel in drug services in England 55 which it thught was gd practice Educatin, training and emplyment Building recvery capital in relatin t educatin, training and emplyment is a challenging area fr thse in OST. Natinal mnitring data 68 cnsistently indicate that thse n OST have lwer levels f educatin and emplyment than the general ppulatin. 56 There is evidence that emplyment utcmes amngst thse n OST (and thse with cmplex needs) are amngst the mst resistant t change, nt least as they are cmpunded by service users having ill health, disability, criminal recrds and pr qualificatins and wrk histry. A review f evidence n vcatinal training fr drug users fund that this apprach was cmmn, althugh there are examples f successful prgrammes in the EU, many have limited r n effects and it is difficult t draw cnclusins abut verall effectiveness. Evidence frm England indicates that the wrk prgramme has had pr success rates with thse in drug treatment. 57 Other evidence indicates that stigma and prejudice amngst emplyers can als mitigate against thse n OST r previusly n OST gaining wrk. 56,58 There is research evidence f the psitive impact f vlunteering n well-being 55 and emerging examples f psitive impacts fr thse in OST r previusly n OST, in terms f prviding meaningful activity and imprving self-esteem. 59,60 ACMD RECOVERY COMMITTEE OPTIMISING OST REPORT 17

18 6.4. Husing There is evidence that stable husing that supprts recvery is beneficial t help drug users achieve a range f recvery utcmes. 61,62,63 Furthermre, flating supprt services are effective at helping sme substance misusers sustain husing. 61 The service users survey reprted relatively high dissatisfactin with the help that they gt with husing; 43 per cent said that it was pr r bad. Frm the evidence heard by the ACMD RC, husing that supprts recvery is prblematic particularly in sme parts f the cuntry including Lndn. 7. NATIONAL FRAMEWORKS, GUIDELINES, ENABLING BODIES AND LEVERS TO MAXIMISE RECOVERY OUTCOMES GUIDANCE AND DELIVERY ASSURANCE The Advisry Cuncil n the Misuse f Drugs (ACMD) Recvery Cmmittee (RC) heard evidence frm Public Health England (PHE) and thers cncerning the fllwing: Extensive, high quality guidance has been develped t encurage recvery-rientated drug treatment. 30,64,65 The PHE Recvery Diagnstic Tlkit (RDT), which prvided lcalities with natinally benchmarked patient and perfrmance prfiles and evidence-based guidance n hw t achieve recvery utcmes. PHE staff als prvided lcal seminars t cmmissiners and prviders n request. A range f regular management infrmatin reprts based n Natinal Drug Treatment Mnitring System (NDTMS) data, which benchmarked lcal areas and services against similar systems t be used t perfrmance manage lcal systems by cmmissiners and prviders. The ACMD RC thught that the guidance dcuments prvided were excellent and f high quality, and evidence-based. It heard mixed feedback n the PHE data reprts; sme cmmissiners and prviders fund them excellent but thers fund them cmplex and difficult either t interpret r t pull ut pririty areas. ACMD RC did nt think that there had been cnsistent use f guidance, the Recvery Diagnstic Tlkit r PHE management infrmatin t imprve the quality f OST. The change in culture with the mve frm the rle f delivery assurance f the Natinal Treatment Agency t a mre hands ff infrmative apprach f PHE was nted, with mixed views by the ACMD RC members and thse wh gave evidence. Cmments by thse wh presented evidence included a lack f levers between natinal and lcal levels, and an unhelpful and increasing reality gap between PHE and what was happening n the grund in treatment services. 8. SERVICE USER FACTORS There is evidence that the ppulatin f herin users in England is reducing 66 and that this is due bth t fewer peple develping herin dependence than in previus years 66 and t thse with herin dependence vercming that dependence and achieving recvery utcmes. 67 A welcme tipping pint appears t have been achieved. There is evidence that an increasing prprtin f thse with herin r piid dependence in England are ver the age f 35 years. 66 Older peple accunt fr an increasing prprtin f the dwindling number f thse with herin dependence wh present fr drug treatment each year. 68 This excludes thse wh receive drug treatment in prisn as they are nt cunted in these statistics. Additinally, bth surces suggest that the number f yung users (aged belw 30) has declined ver the past decade. ACMD RECOVERY COMMITTEE OPTIMISING OST REPORT 18

19 This ageing effect reflects the rise, and subsequent fall, in yung peple initiating herin use that was evident during the herin epidemics f the 1980s and 1990s. 69 Thse yung peple wh started t use 20 t 30 years ag, wh are nw in their 40s r 50s, accunt fr the bulk f the current herin-dependent ppulatin in England. There is evidence that thse with herin dependence in the UK have mre cmplex needs than herin users in ther Eurpean cuntries including: higher rates f use n tp f piid substitutin therapy (OST) prescriptins; mre use f crack ccaine; and, higher rates f unemplyment. 19 There is evidence that many lder herin users have pr physical health and their risk f premature death, frm a range f causes, is much higher than that in the general ppulatin. 70 There is als evidence frm experts by experience, witness and qualitative studies that there is a range f mtivating factrs 71 that prmpt thse with herin dependence t seek OST r drug treatment: sme seek treatment as they want t vercme dependence and change their lives; fr sme treatment is cerced by family r by a referral t a drug service if they have been caught ffending; thers seek OST s that they have a back stp r safety net t prevent withdrawals in case their herin supply runs ut; thers want a break frm a herin-dependent lifestyle but d nt intend t give up herin cmpletely Evidence that peple with herin dependence are mre likely t achieve recvery utcmes There is evidence frm multiple utcme studies that different brad grups f herin users in treatment achieve different utcmes, in terms f prcess indicatrs (fr example, retentin at three mnths r treatment cmpletin) and behaviural utcmes (fr example, cessatin f injecting and/r illicit herin use). Evidence surces include: internatinal studies such as Drug Abuse Treatment Outcme Study (DATOS) 72 ; UK studies: the Natinal Treatment Outcmes Research Study (NTORS) 8 and the Drug Treatment Outcmes Research Study (DTORS) 73 ; and Public Health England (previusly Natinal Treatment Agency) data n drug treatment, restricted management data and published data. The headlines frm these studies indicate the fllwing: There is evidence that thse wh use herin plus crack ccaine at the beginning f drug treatment have wrse utcmes than herin-nly users. 74 There is cnflicting evidence n whether men r wmen have better utcmes frm herin dependence. There is evidence that female herin users have mre cmplex needs than men and are less likely t have psitive utcmes. 75 Hwever, there is als evidence frm the UK that wmen herin users are mre likely t successfully cmplete treatment than men. 76 In 2013 in England a quarter (25%) f thse in OST had been receiving OST fr 5 years r mre as part f an ageing chrt. This trend is als evident acrss Eurpe with the majrity f thse in drug treatment in the EU cmprising herin users in OST wh are ver 40 years ld. 77 There is evidence that herin users frm prfessinal career backgrunds (fr example, dctrs) wh receive OST, detxificatin and intensive mnitring (including randm drug testing) achieve and sustain high rates f abstinence. 78 These individuals ften have significant assets (educatin, prfessin, relatinships, etc.). ACMD RECOVERY COMMITTEE OPTIMISING OST REPORT 19

20 There is evidence that recent chrts f thse with herin dependence wh were new t drug treatment and OST (treatment naïve patients) in England were mre likely t cmplete treatment having vercme herin dependence and be abstinent than previus chrts. 79 Thse in OST in England wh stpped illicit herin n tp during treatment were mre likely t vercme herin dependence, becme abstinent and cmplete treatment successfully particularly if use f herin n tp is within six mnths f starting OST. 79 There is evidence that the mre cmplex patients, and thse with previus experience f OST, were ften in OST treatment fr much lnger perids. Furthermre, thse wh have been in OST fr ver fur years, r thse with lng drug using and treatment careers, are the mst likely t remain in OST and nt achieve abstinence r cmplete treatment. Nt surprisingly evidence shws that the mst cmplex piid dependent clients have the prest rates f treatment cmpletin, being far less likely t cmplete treatment within a year than the lwest cmplexity drug using grup. 79 There is evidence that a minrity (25%) f OST patients in publicly funded treatment in England pssess high recvery strengths. 80 Evidence frm Best et al, 81 fund that stable, high functining OST clients were nearly fur times as likely t cmplete drug treatment having achieved abstinence. Based n a sample f 780 OST clients in the West Midlands f England, this analysis fcused n fur patient dimensins: nt engaged in meaningful activity, nging use f herin and/r crack (38% f the sample); abstinent frm herin and crack but n engagement in meaningful activities (36%); engaged in meaningful activity but nging use f herin and/r crack (13%); and, abstinent frm herin and crack and engaged in meaningful activity (14%). These dimensins were predictive f patients physical and psychlgical health and quality f life. Hwever, meaningful activity was mre strngly related t better health and quality f life than abstinence, which had a much mre limited effect. It is ntable that a minrity f patients (27%) were invlved in meaningful activity Segmenting the herin-dependent ppulatin There are many examples in health where patient ppulatins are gruped in terms f their prbable recvery pathways and then matched t a type f treatment. Examples f patient placement criteria t match individual need t the ptimal treatment interventin are cmmn in health, fr example, the treatment f types f cancer, and in health insurance mdels. There have been similar attempts t devise patient placement criteria r treatment matching in drug and alchl treatment. Sme studies have failed t find treatment matching effects in patient utcmes. 82,83 There is evidence that the severity f patient need is related t bth the length and type f treatment required. 6,7,84 Evidence supprts the effectiveness and efficiency f reserving mre intensive services fr thse with the mst severe prblems (fr example, mre depressed clients shwed significantly better utcmes in treatment including high structure behaviural cunselling). 85 The Advisry Cuncil n the Misuse f Drugs (ACMD) Recvery Cmmittee (RC) heard evidence frm Public Health England (PHE) f wrk being undertaken since 2011, t establish patient placement criteria in England. An expert grup cnsidered three dimensins: addictin severity; health and scial prblem cmplexity; and recvery strengths and then develped a 14-item assessment tl fr use by clinicians, Addictin Dimensins fr Assessment and Persnalised Treatment (ADAPT). 80 When applied t Natinal Drug Treatment Mnitring System (NDTMS) data, three segments r classes f patients emerged: class 1 (25%) relatively lw severity, lw cmplexity and high strengths; class 2 (47%) mderate severity, cmplexity and strengths; and, class 3 (28%) high severity, high cmplexity and lw strengths. ACMD RECOVERY COMMITTEE OPTIMISING OST REPORT 20