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

21

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

2 FOR £15.00)

TESCO EVERYDAY VALUE LAGER 2% (4X440ML)

2% ALC.

£1.00 (5.7P/100ML)

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

26

a complex system

27

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

28

a complex funding system

29

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.

30

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

31

32

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

33

tools to support delivery

more in-depth support to the 14 areas

34

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

72

Guidance and evidence

73

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

74

Guidance…….

75

77

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)