Bristol, 5 October 2012
Leeds, 11 October 2012
London, 15 October 2012
MAKING RECOVERY REAL:THE PUBLIC HEALTH FUTURE OF DRUG AND ALCOHOL TREATMENT
Paul Hayes
Chief Executive, NTA
PROGRESS MADECHALLENGES AHEAD
Drug use is down
Fewer young people are in treatment
More drug users are recovering
Younger people are doing better
People who use heroin are getting older
Crime is down
Policy evolution
2001 - Harm
2005 - Completion
2008 - Abstinence
2010 - Recovery
2012 - Consensus
Strang
Everyone can, not everyone will
50 : 30 : 20
Recovery and, not recovery instead
Humility
Partnership
Optimism
Sketch map not satnav
Reasons to be cheerful
Evidence Consensus
Money Track record LA leadership
Integration PHE
Politics
Worries
£
NHS
Localism / stigma
Alcohol
Jobs and Houses
“New” drugs
Competence
Narrative of failure
Mission
“Give everyone who can, every chance to”
DRUGS AND ALCOHOL AND NTA INTO PHE
Drugs & alcohol in public health
Agenda will need to be championed, strategic partners engaged
Using the data, using the evidence, and making the arguments
Drugs, alcohol, ATM and prevention …
NTA into PHE
NDTMS & NATMS Knowledge & Intelligence
Central policy function Health Improvement
Local teams Operations
Expertise, support, tools continue to be available…
Alcohol Public Health Outcomes Framework indicator will be based on the old NI39: estimates of the number of alcohol-related hospital admissions (ArHA)
Public Health Outcomes Framework – will be estimated numbers of alcohol-related hospital admissions (ArHA)
Prime Minister’s Implementation Unit – will monitor progress against the same indicator
Successful completions and non re-presentations will now be included (or is likely to be included) in the following indicator sets
Public Health Outcome Framework – Successful completion and non re-presentation (partnership only so far and baselines produced)
Prime Minister’s Implementation Unit – Successful completion and non re-presentation (national with expected increases month on month)
PHE day one metric – Successful completions (national with expected increases month on month)
Social Justice Outcome Framework – Proposed successful completion and non re-presentations
Drugs & alcohol in PHE
And the money…
The funding - current understanding(rounded for ease)
Public Health Grant approx £2 billion in total
Pooled drug treatment budget £400m Substance misuseDH DIP funding £ 60m componentYoung people’s substance misuse treatment £ 25m of theLocal drug treatment spend £160m Public HealthAlcohol £???m Grant
Prison substance misuse treatment £100m National Commissioning
Board
HO DIP funding £ 35m PCCs
Alcohol prevention and treatment: now and in the transition to Public Health
England
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alcohol strategy: what’s the problem
Around 9 million people are drinking at levels which are above the NHS guidelines
Of these 2.2 million people (7% of men and 4% of women) are most at risk of illness and death from alcohol
Within this, around 1.6 million have a possible dependence on alcohol
Alcohol harm costs the NHS about £3.5 billion per year
Alcohol-related crime £11 billion per year
Lost productivity due to alcohol about £7.3 billion
alcohol strategy: what does government want to achieve?
change behaviour so people think it is not acceptable to drink in ways that cause themselves or others harm
reduce alcohol-fuelled violent crime
reduce the number of adults drinking above NHS guidelines
reduce the number of people ‘binge drinking’
reduce the number of alcohol related deaths and
sustain reduction in both the numbers of 11-15 years olds drinking and the amounts they consume
alcohol strategy: how government plans to achieve it
Nationally:
• Introduction of a minimum unit price for alcohol to stem the flow of cheap alcohol
• Consult on a ban on multi-buy price promotions in shops
• A review, overseen by the Chief Medical Officer, of the alcohol guidelines
• A new density power to allow licensing authorities to consider local health harms when introducing Cumulative Impact Policies
• There will be an alcohol check within the NHS Health Check for adults from April 2013
STELLA ARTOIS (12X284ML)
. £8.00 ANY
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TESCO EVERYDAY VALUE LAGER 2% (4X440ML)
2% ALC.
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alcohol strategy: what is expected of local areas?
The strategy encourages local government, NHS, Police and Crime Commissioners and other partners to work together to use their new powers and responsibilities
Local authorities and the new Health and Wellbeing Boards will be required to use the ring fenced public health grant to address local public health problems, including reducing alcohol related health harms
Linking to funding via NHS Commissioning Board and CCGs for IBA and hospital based services
Whilst local action is led and delivered by local government and their partners, PHE will be there to support this in every way it can
where we have been
Alcohol treatment system is dependent on local prioritization
Relationship to drug treatment – a nationally driven Government priority
Separate funding streams No performance management of alcohol treatment.Often locally integrated services
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a complex system
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Outlet Density
Minimum pricing
IBA
Child protection Prison
AcuteSector
ATRProbation
Mental Health
AdultSafeguarding
ResidentialCommunitytreatment
Supply reduction
Demandreduction
but guidance exists
Alcohol Learning Centre:http://www.alcohollearningcentre.org.uk/
NICE suite of alcohol guidance:http://www.nice.org.uk/guidance/index.jsp?action=byID&o=11875
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a complex funding system
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Outlet Density
Minimum pricing
LA-Licensing
IBACCGLA/PHENCB
Child protection
LALA/PHE
PrisonNCB
AcuteSectorCCG
ATRProbation
NOMSLA/PHE
Mental HealthCCG
AdultSafeguarding
LA
ResidentialLA/PHE
CommunityTreatment
LA/PHE
Supply reduction
Demandreduction
where we need to get to• Quality Treatment System- Driven by local need
– NICE and other guidance– Appropriately qualified staff– Appropriately commissioned– Inspected by CQC– NATMS
• Recovery focussed– Mutual Aid– Wider than the medical interventions
• Greater integration– PHE for substance misuse– Across multiple domains- A two way street.
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between now and April 2013
Whilst local action is led and delivered by local government and their partners, PHE will be there to support this in every way it can after April
Before then, support to commissioners and DsPH via regional alcohol commissioner forums, focusing on the High Impact Changes (Dept. of Health) and Alcohol Strategy priorities
We will also be working with 14 areas in more depth, building on the work of the Alcohol Improvement Programme
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Regional alcohol networks will be promoted, based on existing arrangements where in place
themed events to draw in key stakeholders such as DsPH and providers and focus on key delivery themes: IBA, hospital based services and NICE compliant specialist treatment
Regional alcohol commissioner forums will be central to the networks and focus on policy updates and priorities
we will explore the use of action learning sets and web forums (via the Alcohol Learning Centre)
continued investment in existing alcohol services in all settings
regional alcohol support
The following tools will be provided to all areas:
Tools Detail
Alcohol JSNA Support Pack Publish end of October
Prevalence Service User Ratio Expert Group held at the end of July agreed methodology. PSUR will be shared with local areas as part of the JSNA process in October 2012
Value for money /’Why invest’ in alcohol services
Expert group held at end of July, with the aim of circulating information in November 2012
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tools to support delivery
more in-depth support to the 14 areas
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14 areas have been offered additional support and expertise from alcohol programme managers
Each region has at least one area Moving forwards this will help PHE shape its alcohol role
• Leeds• Bradford• Newcastle• Middlesbrough• Nottingham• x2 in the NW
• Leeds• Bradford• Newcastle• Middlesbrough• Nottingham• x2 in the NW
• Brighton and Hove• Portsmouth• Hammersmith and
Fulham• Cambridgeshire• Sandwell• Birmingham• Bristol
• Brighton and Hove• Portsmouth• Hammersmith and
Fulham• Cambridgeshire• Sandwell• Birmingham• Bristol
MEDICATIONS IN RECOVERY: RE-ORIENTATING DRUG DEPENDENCE TREATMENTReport of the Recovery Orientated Drug Treatment Expert Group
Content
The problem The chair’s interim report The group’s final report Implementation
The problem
2010 drug strategy:
“Substitute prescribing continues to have a role to play in the treatment of heroin dependence, both in stabilising drug use and supporting detoxification. Medically-assisted recovery can, and does, happen…
However, for too many people currently on a substitute prescription, what should be the first step on the journey to recovery risks ending there. This must change.”
Towards a solution
NTA asked Professor John Strang to chair a group to provide guidance on the proper use of medications to aid recovery
Expert group comprised clinicians, managers, service user representatives, commissioners, researchers and others
Chair’s interim report published July 2011
The interim report - outline
Common ground in the group: strong body of evidence for the effectiveness of opioid substitution treatment (OST) but people in treatment could be better supported in their recovery
Existing guidance (NICE and orange book), and the evidence on which it is based, already describes much of what is best practice
12 immediate steps that can be taken to improve the recovery orientation of treatments that include prescribing
But will also need a renewed emphasis on improving people’s recovery
Areas of work for the group’s final report
RODT - 12 immediate steps overview
Increase recovery-oriented ambition and progress by:examining current practice to make sure there is balance between overcoming dependence and reducing harm, and that recovery care planning is good
checking clients are working towards abstinence and, as more people are ready to come off, make sure they are properly supported
making sure clients are still getting real benefit from prescribing and, if necessary, optimising treatment: adding psychosocials and/or getting dose right
doing more to support people to recover: visible exits from treatment, social networks, employment, housing
making sure staff are competent in all these interventions.
Strang J (2011) Recovery-orientated drug treatment an interim report by Professor John Strang, chair of the expert group. NTA
The group’s final report
The treatment system’s achievements
Numbers in treatment
The treatment system’s achievements
The treatment system’s achievements
Global HIV prevalence in people who inject drugs
The treatment system’s achievements
Drug treatment prevented an estimated 4.9m offences in 2010-11
The treatment system’s achievements
The group’s final report
A lot done.
A lot more to do!
The group’s final report – July 2012
High-quality treatment system that substantially improves health
Heroin is sticky Leaving treatment is important
but it isn’t recovery Lots of people haven’t recovered Done right, OST is effective but a
platform for recovery Don’t end it too early Some people recover fast, some
don’t – all need recovery support
The task set for the field by the group’s report
“Well-delivered OST provides a platform of stability and safety that protects people and creates the time and space for them to move forward in their personal recovery journeys. OST has an important and legitimate place within a recovery orientated system of care.”
“We need to ensure OST is the best platform it can be but focus equally on the quality, range and purposeful management of the broader package of care it sits within.”
McLellan and White commentary
Opioid maintenance and recovery-oriented systems of care: it is time to integrate
“Recovery status is best defined by factors other than medication status. Neither medication assisted treatment of opioid addiction nor the cessation of such treatment by itself constitute recovery. Recovery status instead hinges on broader achievements in health and social functioning - with or without medication support.”
A Thomas McLellan & William White
Avoid unintended consequences
Let’s be clear:
This is about increasing recovery-oriented ambition and progress for individuals and in systems where there is not currently enough of it
It is not about destabilising - to the point of unacceptable risk - individuals who are deriving benefit from OST.
Key to success
A shared vision of recovery, and leadership Organisations & staff able to support and sustain change Staff who believe in the treatment they are delivering A structured programme with clear treatment goals Availability and range of OST medications Range and quality of psychosocial interventions Active referral to self help and mutual aid Links to recovery orientated community organisations
The evidence ...
... is good that OST:Retains people in treatmentSuppresses illicit use of heroin Reduces crimeReduces the risk of BBV Reduces risk of death.
... is less persuasive that OST:Suppresses other drug useImproves physical and mental health Improves social reintegration of marginalised heroin users Promotes abstinence from all drugs.
Quality of pharmacological intervention
Adequate dose Recognise increased metabolism in some Supervised consumption Contingency management to stop use on top Avoid therapeutic nihilism
What should services do?
Do more
Do it quick for those new in treatment,
and purposefully for all
But avoid unintended consequences
Do more
Level 1n=29
Level 2n=34
Level 3n=36
Methadone >65mg >65mg >65mg
Counselling Regular Regular
Other services EmploymentFamily TherapyPsychiatric Care
Random treatment assignments
McLellan et al., (1997) Levels of Treatment in Methadone Maintenance Programs. Treatment Research Institute
Target behaviours at six months
Do it quickly
Greatest improvement seen during first three months Getting treatment right during this period vital to the
recovery process
Kakko J, Grönbladh L, Svanborg KD et al. (2007) Am J Psychiatry 2007; 164:797–803
And finally ...
“There is no justification for poor-quality treatment anywhere in the system.
It is not acceptable to leave people on OST without actively supporting their recovery and regularly reviewing the benefits of their treatment.
Nor is it acceptable to impose time-limits on their treatment that take no account of individual history, needs and circumstances, or the benefits of continued treatment.
Treatment must be supportive and aspirational, realistic and protective.”
Adaptive treatment
Plan, review, optimise (measure) Phases:
Engagement and stabilisationPreparation for changeActive changeCompletion
Layers (of intensity):StandardEnhancedIntensive
Challenge
Implicit in undergoing treatment and also a role of treatment
Challenge in treatment:Difficult to initiate and maintain change to entrenched
patterns of drug-using behaviourRequires concerted effort and focus from everyoneEspecially difficult for those with little recovery capitalTreatment services and staff create the therapeutic
conditions and optimism necessary
Challenge of treatmentContinued drug use or harmful drinkingAmbivalence
Challenge ...
… will mean doing different things with people at different points in the treatment journey:goal settingempathetic listeningexploring the impact and negative consequences of current behaviour and the benefits of changestrategic use of problem recognition to amplify ambivalence about their current position and behaviourmanaging rewards and negative contingenciesinvolving social networks
Recovery support
Peer-role models and peer support Employment support Family and social networks Housing support Improving well-being Post-treatment support
NDTMS- Core data set J
• Pharmacotherapy
• Psychosocial interventions
• Recovery support
• Post treatment recovery support
Staff equipped to achieve better outcomes
Evidence suggests: Workers who have clear techniques and belief in them
achieve better outcomes (goals and structure) Supervision and governance are key Outcomes are greatly influenced by the quality of the
working alliance
Wampold (2001), Bell (1998), Moos (2003)
Metacompetences
“Competent practitioners of psychosocial interventions implement higher-order links between theory and practice in order to plan and guide their practice and, where necessary, adapt an intervention to
individual needs.”
Metacompetences sit above technique competences
About understanding why and when to do something (and when not to do it).
Pilling S, Hesketh K & Mitcheson L (2010) Routes to Recovery: Psychosocial Interventions For Drug Misuse - A framework and toolkit for implementing NICE-recommended treatment interventions. London: BPS & NTA
Recommended interventions
NICE & 2007 Clinical Guidelines:CM, BCT, CBT, CRA, SBNT, etc
But ... research has been disappointing because it neglects:
relationshipsnatural recoverytherapists’ beliefs/theoriespatients’ views, etc.
Focus on change processes
Orford J (2008) Asking the right questions in the right way: the need for a shift in research on psychological treatments for addiction. Addiction103(6):875-85
Process elements common to effective treatment
A knowledgeable, efficient, likeable and encouraging helper who helps ...
reinforce the feeling of need for change (e.g. encourage ‘discrepancy’)
develop commitment to change (e.g. ‘pledges’, ‘change statements’)
develop self-efficacy (e.g. ‘self liberation’, ‘seeing the benefits’)build social support for change.
Orford J (2011)
Change processes, e.g. from MI
Self esteem Competence/self-efficacy Knowledge of problems Knowledge of strategies to change Concern Clear goals
Miller & Rollnick (1991)
Implementation
• .. incorporation and use over time of a new treatment in routine clinical practice (Manuel 2011)
• .. is the least researched component of translating evidence-based approaches into practice (Gotham, 2004)
• Requires synergy between:•Leadership•Culture of innovation•Governance•Training•Supervision
Phases of treatment: plan, review, optimise
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Guidance and evidence
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Commissioning and systems
Unintended consequences:oldNew
Integration Pathways Reintegration
Balanced systems- maintaining gainsComplexity, dual diagnosis and healthMedicines and new drugsService user’s voiceCreativity- ABCD, social enterprises, recovery communities
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Guidance…….
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Public health- broad and diverse, so is treatment.
Slide 78
Recovery support
Linking Treatment with
Recovery Communities(Medications in Recovery chapter 5)
Mark GilmanStrategic Recovery LeadNational Treatment Agency
1. Make Contact - ACCESS
2. Maintain Contact - RETENTION
3. Make Positive Lifestyle ChangesWhole family and community based solutions
“You alone can do it but...
You CANNOT do it alone!”
THE SOCIAL CURE
1980s ‘New Public Health’ 3 Stage Response to Injecting Heroin Epidemic
Recovery and Public Health 2012
SANITATIONAsset Based Community Development
A
B
C
D
Edwin Chadwick John Snow John McKnight
PUBLIC HEALTH PROBLEMS WITH SOCIAL SOLUTIONS
Treatment & Recovery Process• Engagement (e.g. NSP)• Preparation for Recovery • Active change process• Completion of treatment• Introduction to Recovery
Communities
Treatment & Recovery Eco Systems
Treatment Community
Recovery Communities
Treatment Community
Recovery Communities
CHANGE THIS...
TO THIS...
“All by myself...”
In treatment but socially isolated
...SHOULD NEVER BE...
Identifying and changing social networksQ. Who do you spend your time with in a typical week?
‘COMMUNITY AS METHOD’
SOCIAL BEHAVIOUR and NETWORK THERAPY
"The therapeutic value of one addict helping another”
An Asset with
“more than 2 million
members” Wikipedia
Rediscovering AA and Mutual AidRecovery since 1935
“I cant but WE can”
“You alone can do it but you cannot do it
alone”
Issue date: July 2007
NICE clinical guideline 51Developed by the National Collaborating Centre for Mental Health
Drug misuse
Psychosocial interventions
NICE Guidelines
“Staff should routinely provide people who misuse drugs with information about self-help groups.
These groups should normally be based on 12-step principles; for example, Narcotics Anonymous & Cocaine Anonymous. “
Mutual Aid: A NICE Approved Asset
TWELVE STEP FACILITATION (TSF)
Dual carriageway to Recovery’s Social Cure...
RECOVERY
SMART Recovery
SMART Recovery
NA, CA, AA…
“12 Step Fellowships?”
• “Our clients don’t like it, they won’t go…”
• “12 step is not for everyone…”
• “They’re just swapping one addiction for another…”
CPTI
How it works in practice
Family and Social Networks
BEFORE
AFTER
The addition of just one abstinent person to a drinker’s social network increased the
probability of abstinence in the next year by 27% (Litt et al., 2009).
Making Recovery Communities Visible
Challenging & Changing
5 ways to well being in Recovery1.Connect… With people around you. Go to meetings (AA, NA, CA, SMART)
2.Be Active…do something, go for a walk, exercise, do anything.
3.Give… Do something for someone else. Volunteer.
4.Keep Learning… Try something new. Become a student of recovery?
5. Take Notice… Be curious. Be present. ‘The Power of Now’ (Ekhart Tolle)