NTA, 20/11/2012 MEDICATIONS IN RECOVERY: RE-ORIENTATING DRUG DEPENDENCE TREATMENT Report of the Recovery Orientated Drug Treatment Expert Group

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

12 immediate steps – the short version 1AuditAudit the balance between overcoming dependence and reducing harm. 2Review Review patients to ensure they have achieved, or are working towards, abstinence – particularly from their problem drugs. 3OpportunitiesEncourage more patients to take opportunities for achieving greater recovery. 4VisibilityEnsure the eventual exits from treatment are visible from the outset. 5BenefitReview the continuing benefit of ongoing prescribing to patients. 6Support Ensure extra support is available to patients coming off medications, along with rapid re-entry if they relapse. 7OptimiseCheck treatment is optimised, with appropriate range and intensity of interventions. 8Network Support services to improve patients’ access to social networks, including families, mutual aid and peer support. 9Social capital Support individuals to improve their social capital through work, volunteering and training opportunities. 10Competence Ensure keyworkers are competent to deliver a full range of psychosocial interventions. 11PlanReview, and where necessary improve, the quality of recovery care planning. 12SustainabilityWork with housing and employment services to maximise local access to both.

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

Key to success  Vision 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

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

The evidence... ... is good that OST:  Retains people in treatment  Suppresses illicit use of heroin  Reduces crime  Reduces the risk of BBV  Reduces risk of death. ... is less persuasive that OST:  Suppresses other drug use  Improves physical and mental health  Improves social reintegration of marginalised heroin users  Promotes abstinence from all drugs.

Principles and prompts – for commissioners PRINCIPLES AND FEATURESPROMPTS TO TEST WHETHER THEY ARE BEING ACHIEVED Integrated recovery-orientated systems of care are needed to build and maintain recovery Is a full range of treatment options commissioned, including residential rehabilitation, so that there is the necessary flexibility to build a range of treatment and recovery pathways for different needs: from brief interventions for those not needing structured treatment to full packages of care-managed pharmacological, psychosocial and recovery interventions for those with complex needs? Arbitrarily curtailing or limiting the use of OST does not achieve sustainable recovery and is not in the interests of people in treatment or the wider community Do contracts avoid imposing arbitrary time limits on treatment or elements of it, such as prescribing? Are services expected to set clear and ambitious goals for each individual’s treatment, with planned timescales for action, and expect targets for general improvements in treatment and recovery, such as: increased psychosocial interventions hosting of 12-step meetings development of aftercare functions and peer support? Drug treatment is not expected to deliver recovery on its own but can integrate with and benefit from other support Is an integrated recovery-orientated system of care being created that involved other health and social care services with drug treatment to provide recovery support, including mental health, employment, housing, mutual aid, recovery communities, etc?

Methadone helps… and holds people…

Do it quick for those new to treatment  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

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.