Addiction Today

AN INSPECTOR CALLS – ON RESIDENTIAL REHAB

STAR RATINGS AND RESULTS FOR TREATMENT SERVICES

There was great concern among residential rehabilitation services when the Care Standards Act 2000 came into force. Would the sector be discriminated against, even decimated? DAVID FINNEY of the Commission for Social Care Inspection reports

This article was published in Addiction Today journal, March 2008

Residential rehabilitation services have not only survived the Care Standards Act 2000 but have demonstrated high standards of practice which have been reflected in complimentary inspection reports. No doubt articles in Addiction Today, pressure from treatment-centre representative EATA and guidance from the National Treatment Agency for Substance Misuse helped this process. Meanwhile, inspectors in the National Care Standards Commission and its successor body, the Commission for Social Care Inspection, received training, participated in learning sets and utilised guidance specific to this sector.

Latterly, the NTA has surveyed retention in residential rehabilitation services. It has drawn out factors which improve performance and outlined the sector in terms of “models of residential rehabilitation for drug and alcohol misusers”.

So let’s highlight areas where residential rehabilitation services perform well in the delivery of care – as well as some areas where the sector could improve. I will also identify changes in the wider social-care field as well as the treatment sector which will influence the direction of practice and commissioning. I will comment on these and offer pointers on how to adapt and embrace these changes.

Residential Rehab compared with other CARE sectors.

In a recent survey undertaken by the CSCI, residential rehabilitation services were compared with all the other registered residential services for adults across the country. These other services provide care for people with learning disabilities, mental-health issues or physical disability, for example. Key standards were identified and compared across the 18,000 care homes registered with CSCI.

The encouraging news is that residential rehabilitation services exceeded the national average by some way. They met the key standards on 86% of occasions, whereas the national comparator for all services was 82%. Far from being the poor relations of residential care, the rehabilitation services are in reality leading the way in terms of providing good-quality care.

STAR*** RATINGS WILL BE REVEALED.

In the sector, there are many “top performers”. This can be demonstrated by the fact that 56% of services achieve over 90% of the key standards. This compares with 43% across other sectors.

The implication is that when the “star ratings” of care homes is introduced in April 2008, there is strong likelihood that a high number of services will be rated as “good” or “excellent”. These ratings will be publicly available so people hoping to come into residential rehabilitation or the purchasers of services will able to see which are the top performers. As of April, this information is available on the CSCI website.

In what ways do residential rehabilitation services demonstrate that they are providing a good service? How is this useful for people who use the services?

Outcomes for people USING services.

This past year, CSCI moved from concentrating on standards toward looking at outcomes for people who use treatment services. Inspectors have been asking the question “What is it like living in these services?”.

Far from looking only at inputs such as the physical environment, health & safety and documentation, inspectors have been exploring the quality of care and the experience of people living in each service. This is an area where residential rehabilitation services score highly.

What does residential rehabilitation do particularly well? I have selected some key areas where the sector provides good-quality care. Examples of good practice are highlighted through direct quotes from inspection reports.

reclaiming lives.

The most striking result comes in the area of “living a fulfilling life” where the outcome was met on 97% of occasions.

Inspectors comment on matters which are central to a person’s treatment and recovery. They quote people living in the services who say “This is an excellent programme, much more challenging than I have previously experienced” and “I have really started to look at my life and how I need to change”. Others have said that “This programme has saved my life, and helped me help others to save their lives… I am happy with the person I am, I actually like me, I don’t have to pretend to be somebody I am not… the future belongs to me”.

In my view, this is absolutely central for a person wishing to achieve a good recovery. So it is particularly heartening to see that the sector is seen to promote fulfilment so well.

When looking at documentation, it is also interesting to see that inspectors found that plans kept by the services show clear progression and achievement of agreed goals. This is important confirmation that fulfilment is promoted and achieved. In turn, this provides good evidence for placing/purchasing bodies, such as Drug/Alcohol action Teams, that the services are achieving the aims of the placement and so worth purchasing.

Other aspects of fulfilment which inspectors comment on are activities, relationships, and a sense of re-integration into society. Inspectors note that “Activities are chosen to contribute to the sense of community in the service and to promote the work of recovery”.

Also they comment that the people who use services are “encouraged to maintain and rebuild relationships which are appropriate”.

Finally, one programme is described as “requiring residents to take more responsibility for planning a future beyond (the service)”.

Inspectors often experience a sense of engagement with the people living in the services they visit. For example, one inspector commented that “the atmosphere was vibrant and residents readily discussed life in (the service)”.

Choice and Control.

This is an area where it might be thought that people in residential rehabilitation lose out due to restrictions placed on them and requirements to attend programmes. Instead, this scored highly in CSCI inspection reports – with the standard being met on 90% of occasions.

Inspectors reported that “People are supported in making their own decisions and in becoming responsible for their own recovery”. When entering a service, it is important that restrictions intrinsic to programmes are spelt out in advance and agreed with the prospective resident. One person commented that “I got the booklet about the service and was interviewed by the key worker before I decided to come”.

The standards ask for a Service User Guide and this has been produced and used effectively throughout the sector as a demonstration of an increasing openness to the choice, control and responsibility exercised by people entering rehabilitation. There is a range of treatment approaches on offer in this sector, so it is important that both people entering treatment and commissioners are given good information about the philosophy behind say, 12-step, therapeutic communities or harm-reduction approaches. This enables them to choose the appropriate service for their needs. Success is more likely to be achieved this way.

Health & Well Being.

Compared with other sectors, the residential rehabilitation sector again performs well. Overall, the standard was met on 87% of occasions whereas the national comparator is 83%.

This means that people receive support in the way they prefer, their physical and emotional health needs are met and there are good medication procedures in place. Also, their assessed and changing needs and personal goals are reflected in their individual plan.

All of these factors add up to good packages of care being delivered in a way which is useful to people using residential rehabilitation services. Inspectors often comment that “people using services are involved in developing and reviewing their care plans and are encouraged to reflect upon their life’s events and how these have affected them”. Another external stakeholder added that “One of the things that this service does well is planning and implementing care for service users”. Most services recognise that care plans are subject to very regular review, sometimes daily, and this is recognised and positively viewed by inspectors.

Where detoxification is undertaken, positive comments are made about the medication regimes that are crucial to recovery.

In addition, the food on offer in residential rehabilitation is part of the inspection process. One inspector explained that “The provision of a healthy diet and promoting a healthier lifestyle plays an important role in this unit as the programme is designed to overcome the often chaotic lifestyle of the service users”.

Concerns and complaints.

It is well recognised that people in residential rehabilitation services can be vocal when it comes to expressing their needs and making complaints. The evidence is that they felt listened to by their key workers and managers in the services.

This standard was met in a high number of instances: 89%. There are two major reasons for the high score. The first is the success of “residents’ meetings” which were found to be regular (most often weekly), well run, open, fair and  well recorded.

Secondly, there were good relationships with staff who showed good listening skills in an open relationship.  It is my view that services which listen to concerns and complaints in a constructive way are able to improve the way they deliver their treatment programmes.

Furthermore, inspectors found that the procedures which protect patients from abuse were working well in 81% of services compared with the national average of 79% of services.

Sometimes there were alterations needed to ensure that all the local safeguarding information was accurate.

So far, so good. On the next page, we investigate the areas which need improvement.

Areas to improve.

Naturally, there are areas where CSCI inspectors felt that improvement was necessary. Following these recommendations will enable the sector to ensure that it is providing the highest quality of care possible.

The first area was in the recruitment of staff. For example, there were some instances where two references for new staff had not been taken up or where staff had begun work before the CRB criminal-records bureau check had been completed. These are procedural matters which can be improved when good auditing and tracking arrangements are in place. People need to be sure that the staff supporting them are safe through proper checking. Having said this, the standard was met on 69% of occasions.

The next area for improvement was the keeping of health and safety policies and procedures. That was also met on 69% of occasions. Sometimes this was down to fire-safety drills not carried out regularly enough, other times it was to do with following up environmental-health recommendations on food labelling or storage. Usually these were minor points but nevertheless important to the health and welfare of people living in services if they not put right.

For the future.

A key change to inspection will mean that each service will have a “quality rating” published from April 2008 onwards.

This will mean that prospective residents, commissioners, care managers and the general public will know if a service has been assessed as “excellent, good, adequate or poor”. In its work with local authorities, CSCI will be asking hard questions where poor or even adequate services are being routinely purchased.

The Healthcare Commission and NTA Joint Service Review for Substance Misuse will look specifically at Tier 4 services and decide if local partnerships as well as individual services are integrated and effective. The improvement planning which results will be key to the provision of quality services across the sector.

Further to this, wider governmental policy initiatives will soon have an effect on this sector. Of prime importance is the “personalisation agenda” promoted by the Department of Health. The aim is to move thinking...

1. From “passive client to active citizen”
2. From “Welfare to well Being”
3. From “Dependence on services to independence through services”
4. From “State donates to a state where people control and choose”.

This will lead to individual budgets for people using services and a culture where quality is determined by people who use services.

This approach will be a challenge for the residential rehabilitation sector. But it is my view that this is not as radical as it might appear at first sight. People entering residential services are making an “investment” in their future recovery. Currently, they mainly think of the emotional and relational resources they are committing to this task. In the future they could be more fully involved in the financial implications. This will be a concrete demonstration of their commitment to change.

In my view, enabling people living in services to participate even more actively in their recovery is an extension of the active participation in therapeutic work, similar to the “sign up” required in a therapeutic community, and in line with the rigorous self-assessment required of someone working through a 12-step programme.

The next steps will involve communicating with commissioners that this is what is happening in the residential rehabilitation sector.

Finally, there will be a new-look regulator in April 2009 called the Care Quality Commission. This will involve a merger of the HealthCare Commission, the Commission for Social Care Inspection and the Mental Health Act Commissioners. To effect this change, a new Social Care Bill is currently proceeding through parliament. I will bring you news of these developments on another occasion!

Conclusion.

The residential rehabilitation sector has much to be proud of in the way it delivers high quality of care. People who use services can be reassured that care is delivered in a way which promotes their recovery, enables them to live a fulfilled life and assists them in regaining choice and control in their lives. The future for residential rehabilitation depends on how well the links are made between the new social care agenda and provision on the ground.

References:

D Boyd: Death of Rehabs? in Addiction Today Sep/Oct 2001.

CSCI: Guidance for Inspectors of Residential Rehabilitation services for people recovering from drug or alcohol addiction (www.csci.org.uk)

NTA: A national survey of retention in residential rehabilitation services, June 2005.   

NTA: Models of residential rehabilitation for drug and alcohol misusers, October 2006.

BRITAIN’S ACCIDENTAL DRUG ADDICTS

Help is needed

Guidelines state that Benzodiazepine tranquilisers should not be prescribed for more than four weeks - but Yours magazine is leading on the story that about 1.1million UK adults, mainly over 50, are addicted to benzos and that little is being done to help them.

MPs on the All Party Parliamentary Drug Misuse Group have become so concerned about the scale of benzo and other prescription drug misuse that a public inquiry is underway.

Dr Brian Iddon, MP for Bolton South East , who is chairing the inquiry told Yours: “This problem should have gone away by now – but in fact it’s worse. GPs are still not following the prescribing guidelines on this. I’m not disputing these drugs can be useful… but in some areas they are still giving them out like Smarties.”

In 2006, some 10,768,910 prescriptions were given to patients, including Yours reader Kathleen Dunion. Kathleen said, “I feel they’ve (benzos) robbed me of my life. The past 35 years have been misery. I’ve been suicidal at some points and felt I just couldn’t go on. It’s only the thought of my family that that stopped me. Last time I felt like ending it, I saw the faces of my two great grandsons and  knew I had to go on for them. I love them so much.  I just want to be the old me and for my children and grandchildren to have the real me back too.”

Despite the scale of tranquiliser addiction in the UK, dedicated withdrawal programmes for benzos are almost non existent.  The only NHS project in England, set up in 2005 by the Oldham Drug and Alcohol Service, receives £55,000 a year in funding compared to the £1.67 million set aside for dealing with illegal drug users in the area.

Tess, 78, is one of the lucky ones. She was admitted to hospital for a two-week withdrawal programme. “The withdrawal symptoms were terrible, my whole body tensed up and it was as if I had a vice around my head. But in other ways it was like a magic wand had been waved over me,” she said. “I could concentrate again for the first time in 21 years, I got to know my children all over again and on Mother’s Day they sent me a wonderful card saying ‘We’re so glad we’ve got our real mum back’.”

Jim Dobbin, MP chairman of the parliamentary All Party Action Group on  Involuntary Tranquiliser Addiction, added that “The Department of Health should look at the Oldham project for benzodiazepine withdrawal and every  Primary Care Trust  should have a facility or support system in place. People think this was all sorted out 20 years ago but nothing could be further from the truth”.

For more information, contact Natalie Trice 

ORGANISATIONS TREATING ALCOHOL DEPENDENCE ARE NOT ON STAKEHOLDER LIST FOR Nice GUIDELINE ON ALCOHOL DEPENDENCE

“I was alarmed not to see the many treatment centres specialising in recovery from alcohol dependence NOT represented on the list of stakeholders informing/steering the Management of Alcohol Dependence  guidelines from the National Institute for Health & Clinical Excellence,” reports Addiction Today editor Deirdre Boyd.

The Addiction Recovery Foundation charity has re-registered as a stakeholder, offering a clinical, research and experiential knowledge base built since 1989.

In October last year, the Department of Health formally requested Nice to “prepare a clinical guideline on the Management of alcohol dependence, including the management of alcohol-related brain damage”. To ensure best practice for patients who desperately need care, addiction-treatment organisations can read details here. 

To download a Stakeholder registration form, click here.

RELATED GUIDELINES IN PROGRESS

The DoH also tasked Nice to produce “combined health and clinical guidance on Management of alcohol use disorders in adults and adolescents”. Click here for details.

Of related interest, given its large overlap with ‘medicating’ through addictive use of substances and its role in relapse, are guidelines on Depression.  Click here for details.

For similar reasons, also of interest are the Nice guidelines on Personality disorders – borderline, due in December this year. The consultation on the draft guideline with stakeholders will start in June 2008. Read more here.

Register as a stakeholder

WADA FIGHTS DRUGS IN SPORTS

John Fahey, chief of the World Anti-Doping Agency and leading the global fight against drugs in sport has urged governments to speed up their implementation of anti-doping laws.

Of the 191 countries that agreed to implement a United Nations-backed anti-drugs convention in 2003, only 77 have so far done so.

"Without government support, we cannot address many issues at national level, including the production, possession and distribution of banned substances," he urged. "The sad reality is that many governments are yet to outlaw such practices."

Despite his frustration, he said things were improving. He told the BBC that Wada had been working with the International Olympic Committee and the Chinese organisers to ensure the anti-drugs framework would be stronger than ever at the upcoming Beijing Olympics.

Wada director general David Howman confirmed that leading athletes competing in the Beijing Olympics would be targeted for pre-Olympic, out-of-competition testing by an International Olympic Committee anti-doping task force. "We will give the IOC advice on who to target," he said. "I want athletes to be really worried that they're going to get caught."

Fahey, a former Australian finance minister, took charge of Wada in January, replacing former president Dick Pound. He is due to hold meetings with sports minister Gerry Sutcliffe and Fifa president Sepp Blatter.

METHAMPHETAMINES: RECOVERY IS POSSIBLE

Ice, the devil’s drug, poor man’s cocaine...

In view of recent warnings from the Association of Chief Police Officers about a methamphetamine epidemic in the UK, we republish an Addiction Today article from 2005 on the opportunities to recover from dependency/addiction to it.

Over 42million people use methamphetamines, amid claims that only 5% of people dependent on it can recover so there is no point in funding treatment. RACHEL GONZALES and RICHARD RAWSON review the research on effective treatments...

Which of the following statements are true or false:

• 70% of first-time methamphetamine – MA – users are hooked after the first try
• only 5% of MA addicts can kick it and stay away
• from the first hit to the last breath, the life expectancy of a habitual MA user is only five years.

All three ‘facts’ are false – the first two have never been studied and would be difficult, if not impossible, to determine. The third is false. Yet these statements have been widely cited, even by a website set up by a US attorney general’s office.

In 2003, Rolling Stone magazine carried an article, Plague In The Heartland, which claimed that “only 6% of MA freaks get and stay sober, the lowest by far for any drug”. An extensive literature search has failed to find any data to support the article’s negative claims. But, sadly, these statements have been used to argue against spending money on an apparently hopeless task of treating MA users.

PREVALENCE

MA was once seen as a harmless pick-me-up but is now known as the devil’s drug or poor man’s cocaine, as well as chalk, crank, fire, ice, glass, crystal, ya ba or simply meth. Its use has risen drastically in recent years: worldwide, over 42million people regularly consume amphetamines, according to the United Nations Office of Drug Control – more than any other illicit drug except cannabis.

Much of the allure and abundance of MA can be attributed to its convenience. Like fast food, MA is widely available and cheap. Unlike most drugs which must be imported from other countries, MA can be made by almost anyone in home ‘labs’. Recipes and step-by-step instructions on how to make it are widely available on the internet. The main ingredients, ephedrine and pseudoephedrine, can be found in many over-the-counter cold and asthma medicines. Items such as battery acid, hydrochloric acid, anhydrous ammonia, drain cleaner, rubbing alcohol, petrol, antifreeze, lamp fuel and cleaning products are among the ingredients commonly used to make MA. Labs can be set up at home, in a garage, even in a hotel room. There are also ‘superlabs’ operated by major drug-trafficking organisations from the US to the far east. Restrictions on retail pseudoephedrine supplies might slow MA production by home labs but will have little if any effect on superlab MA production.

PHYSIOLOGY

MA stimulates the central nervous system. The euphoria ‘high’ produced by it is directly linked to the release of the brain’s ‘feel good’ chemical dopamine. The high is especially immediate and powerful when the drug is smoked or injected, while the stimulant effects – increased energy, confidence, talkativeness, sex drive, decreased fatigue and depression – last for 10 to 12 hours. Advances in brian imaging techniques show major abnormalities and deficits – linked to MA abuse – in the parts of the brain responsible for feelings of pleasure and other emotions as well as memory and judgment. These effects have great impact on the functioning of users during recovery, needing many months’ recovery, but most appear to be reversible.

The substantial health problems linked with MA dependency include severe weight loss, sleep disorders, damage to the cardiovascular system, stroke and severe dental and skin problems. MA use is a factor in the spread of both HIV and hepatitis C.

TREATMENT: MEDICATIONS

No medications have evidence of efficacy in treating MA intoxication, psychosis, withdrawal or dependence. The National Institute of Drug Abuse commissioned research into this. Five sites coordinated by UCLA have tested medications, and other promising ones are planned for testing. In the meantime, when people with MA-induced psychosis present in emergency rooms or other health facilities, they are usually treated with a combination of atypical antipsychotics and benzodiazepines to calm them and prevent them from injuring themselves or others, until the psychosis-inducing effects of MA have dissipated.

TREATMENT: PSCHOSOCIAL/BEHAVIOURAL

There are two approaches with evidence to support their efficacy. And, although there are differences in the pharmacology and physiological effects of MA and cocaine, they have many common properties and effects so research into treatment for cocaine use is helpful.

Research examining the treatment responses of MA and cocaine users suggests that they have similar outcomes when exposed to the same treatments. And large-scale treatment-system evaluations report comparable outcomes for MA and cocaine users. Despite extensive examination of multiple data sources, no data supports the oft-misused ‘statistics’ mentioned earlier, or the contention of poorer outcome results with adult MA users.

TREATMENT: LARGEST CONTROLLED STUDY

In the 1980s, the Matrix Institute on Addictions group – including one of this article’s authors, Rawson – developed a multi-element treatment manual for outpatient stimulant users. This evolved to incorporate evidence-based treatment elements including cognitive behavioural therapies/relapse-prevention techniques, a positively reinforcing treatment context, components of motivational interviewing, family involvement, accurate psycho-educational information, 12-step facilitation efforts and regular urine testing. The approach is delivered using group and individual sessions about three times per week over 16 weeks, followed by a 36-week continuing-care support group and 12-step programme participation.

Over 15,000 MA and cocaine users have been treated with this approach over the past 20 years (manuals at www.samhsa.gov and www.hazelden.org).

In 1999, Csat funded a large-scale evaluation of the Matrix model for MA users, coordinated by the UCLA. About 1,000 MA-dependent people were admitted into eight treatment study sites. In each, 50% of the participants were assigned to Matrix treatment or a ‘treatment as usual’ condition which consisted of a variety of counselling techniques idiosyncratic to each site. The study showed that people in the Matrix approach received more treatment services, were retained in treatment longer, gave more MA-negative urine samples, and completed treatment at a higher rather than those in the TAI condition.

When data at discharge and follow-up were examined, it appeared that both treatment conditions produced comparable post-treatment outcomes. Participants in both showed significant improvements in psychosocial functioning and substantial reductions in MA use and psychological symptoms including depression. Follow-up data indicated that over 60% of both treatment groups reported no MA use and gave negative urine samples for MA and cocaine. Use of drugs such as alcohol and cannabis was significantly reduced also.

Interestingly, the ‘drug court’ site gave the best results, suggesting a substantial beneficial influence of drug-court involvement.

TREATMENT: CONTINGENCY MANAGEMENT

Many treatment programmes include positive reinforcement, be it in the form of verbal praise or privileges. CM is the systematic application of these principles. In many studies investigating CM approaches, treatment participants can earn ‘vouchers’ exchangeable for non-monetary desired items such as groceries or film tickets. Typically, the client can earn larger-valued rewards for longer periods of continuous abstinence from drugs and alcohol.

Over the past 30 years, researchers at Johns Hopkins, UCLA and other universities have shown the powerful effects of CM techniques to reduce heroin, benzodiazepine, cocaine and nicotine use. Recently, CM techniques implemented with MA users in UCLA and the Nida clinical trials network provided powerful support to the efficacy of this behavioural strategy as treatment for MA abuse. Clients using it showed better retention in treatment, lower rates of MA use and longer periods of sustained abstinence.

COCAINE vs METHAMPHETAMINE OUTCOMES.

In a large study using the Matrix model, 500 MA-dependent patients were treated alongside 250 cocaine-dependent patients at the same clinic, by the same staff, over the same time, using the same approach. Treatment outcomes were identical both during treatment and at follow-up. Similar findings have been reported from other treatment studies. These tend to dispel the false beliefs about treatment effectiveness for MA addiction circulating in the public sphere.

CLIENT PROFILES AND TREATMENT IMPLICATIONS

MA abusers come to treatment with unique health and demographic profiles. For instance, when presenting for treatment they consistently have severe psychiatric problems, including psychoses, hallucinations, suicidal ideation, severe depression and cognitive impairments.

It is unclear how much of this is directly related to the effects of the drug and what role comorbidity plays. But clinicians treating MA dependency must be educated about working with patients who have clinically significant levels of disordered thinking and persisting paranoia.

Historically, MA use has been via intranasal and injection routes of administration. But in the past decade smoking has become the more dominant route and some areas report elevated rates of MA injection, both of which seem to lead to a more difficult addiction. Injection users tend to report far more severe craving during their recovery and they have higher rates of depression and other psychological symptoms before, during and after treatment. They also have higher dropout rates and exhibit higher rates of MA during treatment.

In addition, recent reports have documented an extremely powerful relationship between MA use and sexual behaviour – stronger even than cocaine or alcohol. Issues around sexual readjustment during sobriety are very important and can play a large role in relapse if not properly addressed. Also linked to this are high rates of HIV and hepatitis C, so there must be a strong message about minimising or preventing risky sexual behaviours which expose users to these viruses.

Surveys also suggest that women are likely to be attracted to MA for weight loss and to control symptoms of depression. MA can pose different challenges to their health, can progress differently and might need different treatment approaches than for men. Over 70% of

MA-dependent women report histories of physical and sexual abuse. Many women with young children do not seek treatment or drop out early due to the fear of not taking care of their children. All these gender-specific issues need to be addressed.

Although there are unique clinical symptoms, it is not necessary to design completely new approaches for MA dependency. Rather, focus should be on enhancing existing treatment regimes with supplemental services addressing the underlying differences in MA patients.

REFERENCES

Brecht ML, O’Brien A, von Mayrhauser C & Anglin MD 2004: Methamphetamine use behaviours and gender differences; Addictive Behaviors 29(1), 89-106.

Copeland AL & Sorensen JL 2001: Differences between methamphetamine uswers and cocaine users in treatment; Drug & Alcohol Dependence 62(1), 91-5.

Farabee D, Prendergast M & Cartier L 2002: Methamphetamine use and HIV risk among substance-abusing offenders; Journal of Psychoactive Drugs 34(3), 295-300.

Freese TE, Obert J, Dickow A, Cohen J & Lord RH 2000: Methamphetamine abuse issues for special populations; Journal of Psychoactive Drugs 32(2), 177-182.

Hser Y-I, Evans E & Yu-Chuang H 2005: Treatment outcomes among women and men Methamphetamine abusers in California; Journal of Substance Abuse 28, 77-85.

Hser Y-I, Yu-Chuang H, Chou C-P & Anglin MD 2003: Longitudinal patterns of treatment utilisation and outcomes among methamphetamine abusers: a growth curve modelling approach; Jnl of Drug Issues 33, 921-938.

Huber A, Ling W, Shoptaw S, Gulati V, Brethen P & Rawson R 1997: Integrating treatments for methamphetamine abuse: a psychosocial perspective; Journal of Addictive Diseases 16, 41-50.

Rawson RA, Gonzales R & Brethen P 2002: Treatment of methamphetamine use disorders: an update; Journal of Substance Abuse Treatment 23, 145-150.

Rawson R, Huber A, Brethen P, Obert J, Gulati V, Shoptaw S & Ling W 2000: Methamphetamine and cocaine users: differences in characteristics and treatment retention; Journal of Psychoactive Drugs 332(2), 233-238.S

Rawson R, Huber A, Brethen P, Obert J, Gulati V, Shoptaw S & Ling W 2002: Status of methamphetamine users 2-5 years after outpatient treatment; Jnl of Addictive Disorders 21(1), 107-119.

Rawson RA, Maranelli-Casey P, Anglin MD, Dickow A, Frazier Y, Gallagher C, Galloway GP, Herrell J, Huber A, McCann MJ, Obert J, Pennell S, Reiber C, Vandersloot D & Zweben J 2004: A multi-site comparison of psychosocial approaches for the treatment of methamphetamine dependence; Addiction 99(6), 708-717.

Rawson RA, McCann M, Flammino F, Shoptaw S, Miotto K, Reiber C & Ling W 2005: A comparison of contingency management and cognitive-behavioural approaches for cocaine and methamphetamine dependent individuals; recently submitted to Addiction 2005.

WITH THANKS TO:

Neca Logan and Stephanie Muller, respectively director of professional publishing and editor of the US Counselor magazine, through whose good offices we bring readers this article.

Richard Rawson PhD is the associate director of the  UCLA School of Medicine’s Integrated Substance Abuse Programs. His portfolio of addiction research ranges from brain imaging studies to clinical trials on pharmacological and psychosocial treatments, to the study of how new treatments are applied in the healthcare system.

Rachel Gonzalez MPH has several years’ experience in the field of substance-abuse practice and research, has worked in UCLA’s integrated substance abuse programmes and was codirector and codeveloper for Project Empact, an anti-tobacco media literacy curriculum for adolescents

DRUG STRATEGY 2008-2018: treatment details

The following are the promises made in the strategy regarding treatment for drug-and alcohol problems, as well as the proposed action plans - available in full at Drugs: protecting families and communities – 2008-2018 strategy (1Mb pdf file) and at Drugs: protecting families and communities - Action plan 2008-2018 (1Mb pdf file)

“THE GOVERNMENT WILL...

...Clearly prioritise those who are causing the most harm to communities and families – getting offenders, and parents whose drug use may put their children at risk, into effective treatment quickly.

...Pilot the use of individual budgets to help those successfully completing treatment to access housing, employment, education and training, to support them in re-establishing their lives, free from dependency.

...Use all emerging and available evidence to make sure we are supporting the treatment that is most effective, targeted on the right users – with abstinence-based treatment for some, drug-replacement over time for others, and innovative treatments including injectable heroin and methadone where they have been proved to work and reduce crime.

...Involve families and carers in the planning and process of treatment, for young people and for adults.

...Ensure that the benefits system supports our new focus on re-integration and personalisation. To ensure that it creates incentives for people with drug problems to move towards treatment, training and employment, we will at a minimum:

– require drug misusers on out-of-work benefits to attend a discussion with an appropriate specialist treatment provider or partner organisation as part of the Jobseeker Direction or Work Focused Interview requirements; and

– encourage closer links between relevant agencies so that drug misusers who are claiming benefits can be referred to specialist services."

These changes are a first step in helping clients to overcome barriers to work and ensuring Jobcentre Plus engages more closely with local drug partnerships and treatment providers. It is not right for the taxpayer to help sustain drug habits when individuals could be getting treatment and overcoming barriers to employment. So it is proposed to introduce a regime with more tailored and personalised support . In return for benefit payments, claimants will have a responsibility to move successfully through treatment and into employment. “ Further proposals will be announced regarding these measures."

PREVENTION

The strategy will expand its approach so that it increasingly focuses on young children and families before problems have arisen.

It will take a wider preventative view that is not focused just on illegal drugs, but on all substances and the risk factors that we know can lead to drug use, alcohol misuse and volatile substance abuse (gases, glues and solvents) as well as other problems later in life.

Ant it will look at the whole family, ensuring prompt access to treatment for drug-misusing parents with treatment needs and particularly those whose children are at risk, with assessments taking account of family needs, and providing intensive parenting support alongside drug treatment.

KEY STRATEGY ACTIONS

Develop pilots to test new approaches which can provide better end-to-end management through the system, including a more effective use of pooled funding and individual budgets, and with a sharper focus on outcomes.

Develop a package of support to help drug users, particularly those causing the most harm, to access and complete treatment and to re-integrate into society.

Use opportunities presented by the benefits system to provide support and create incentives to move towards treatment, training and employment.

Ensure treatment is personalised and outcome –focused, making full use of new treatment approaches which are shown to be effective.

Draw on significant new funding to support research into developing better forms of treatment.

NEW APPROACH IN DETAIL

“The goal of all treatment is for drug users to achieve abstinence from their drug – or drugs – of dependency," states the strategy.

"For some, this can be achieved immediately, but many others will first need a period of drug-assisted treatment with prescribed medication. Drug users receiving drug-assisted treatment should experience a rapid improvement in their overall health and their ability to work, participate in training or support their families. They will then be supported in trying to achieve abstinence as soon as they can."

While large numbers are entering drug treatment, with most deriving significant benefit from it, too many drug users relapse, do not complete treatment programmes, or stay in treatment for too long before re‑establishing their lives. The challenge is to maximise the impact of treatment for those who receive it. There sould be more personalised approaches to treatment services, which have the flexibility to respond to individual circumstances. The government will examine how to best support those leaving and planning to leave treatment with packages of support to access housing, education, training and employment. "We will deliver better outcomes, with more people becoming re-integrated into society, through a focus on four key objectives."

TARGETING THOSE MOST AT RISK

The Department of Health has lead responsibility for delivering effective drug treatment and will continue to prioritise heroin and crack use, while improving access for under-represented groups and those with complex needs by:

• addressing unmet treatment needs and barriers to treatment, which may include the needs of young people, women, crack or poly-drug users, particular black and ethnic or other minority communities, sex workers or parents with dependent children;

• removing barriers to accessing services for users with children, and acting promptly to protect children where they are found to be at risk;

• targeting services for those with complex needs, such as drug users with mental health problems; and

• prioritising access to treatment for those drug-misusing offenders who enter through DIP and those leaving prison or completing the DRR of a community sentence or a period on licence.

IMPROVING QUALITY AND EFFECTIVENESS OF TREATMENT

Better outcomes for people entering treatment should be achieved by:

• improving retention of clients in treatment, with more clients overcoming drug dependence and successfully completing treatment programmes and re-integrating into communities;

• driving up standards across all treatment providers through new local clinical governance arrangements and by monitoring a range of treatment outcomes, including re-offending, employment and health;

• improving, where appropriate, the sharing of information between agencies to facilitate the management of clients;

• continuing to promote harm minimisation measures including needle exchange and drug-assisted treatments that encourage drug users to enter treatment, to reduce the risk of overdose for drug users and the risk of infection for the wider community; and

• improving commissioning skills and continuing to engage service users in the planning and delivery of services at a local level, to ensure that services are responsive to local needs.

NEW TREATMENT APPROACHES

The government says it  will build on new evidence of what works and maximise the range of approaches used, including by:

• using contingency management pilots, in which positive reinforcement techniques are used to encourage clients to maintain a course of treatment, to identify and reinforce good practice and address concerns about the inappropriate use of rewards in treatment;

• encouraging clients and family members to make wider use of mutual aid support networks, such as abstinence programmes and local support groups, to improve treatment outcomes;

• developing and delivering a significant new initiative to support research that will boost understanding of addiction and identify opportunities for new forms of treatment or prevention. Building on the major expansion of health research funding from the last Spending Review, the Medical Research Council and the National Institute for Health Research agreed that addiction should be one of the joint priority areas for health research funding, led by the Medical Research Council;

• applying learning about what works gathered through the routine monitoring of treatment outcomes through, for example, the National Drug Treatment Monitoring System; and

• rolling out the prescription of injectable heroin and methadone to clients who do not respond to other forms of treatment, subject to the findings, due in 2009, of pilots exploring the use of this type of treatment.

“RADICAL NEW FOCUS" TO RE-ESTABLISH LIVES

The ambition of this strategy is to achieve sustainable reductions in the harms caused by drugs. Drug problems do not occur in isolation, and may be both the cause and the consequence of wider social and personal problems. The government’s programmes to tackle social exclusion among adults and at risk families recognise that people or places can become trapped in a cycle of related problems, such as unemployment, poor skills, low incomes, poverty, poor housing, high crime, bad health and family breakdown – all factors which can be related to higher levels of drug use.

To address the wider problems faced by those affected by drugs, this strategy is linked with the framework set out in Reaching Out: An Action Plan on Social Exclusion and the Families at Risk Review and will draw on the Adults Facing Chronic Exclusion Programme as part of a package of action, social care and support to help individuals and families to re-integrate themselves in the community.

It will also make full use of the Working Neighbourhoods Fund, a £1.5billion contribution to the Area Based Grant launched in November 2007 to help local authoritiy areas facing challenges of worklessness and low levels of skills and enterprise. The Working Neighbourhoods Fund has been allocated to 87 local authority areas for 2008-2011.

For drug misusers, the Department of Health, the Department for Work and Pensions and the Department for Communities and Local Government will take the lead on work to support drug misusers’ re-integration into society by:

• encouraging joint working between treatment agencies, Jobcentres and sources of housing advocacy and advice, to plan and manage clients’ journeys through treatment and into work, helping them access the wider support they need to re-establish their lives;

• encouraging local authorities to work with partners to meet locally-identified need for housing and support for those affected by drug misuse;

• allowing the Pooled Treatment Budget to be used alongside other funding streams to provide advice on re-integration support and case management;

• ensuring that all local partners are aware of the need to assess the wider needs of drug misusers and those in treatmen