An approach to disinvestment in the field of drug addiction treatment A. Camposeragna, L. Amato, E. Parmelli, M. Davoli

Declaration No conflict of interest

Value for Money in Health Spending is a “mantra” given the recent economic downturn NHS offers a wide range of interventions although some are uncertain to be beneficial for people's health The great amount of available literature, sometimes contradictory, as well as its not easy access, contributes to the complexity of the decision-making process.

Effectiveness of 3000 treatments as reported in randomised clinical trial selected by Clinical Evidence. 2016

http://clinicalevidence. bmj http://clinicalevidence.bmj.com/x/set/static/cms/efficacy-categorisations.html

Background An intervention or a practice is low value if: It is not clinically effective it can be unsafe for sub-groups of patients (or all) it is used inappropriately Both for financial and ethical issues, it is beneficial reducing or stopping health care interventions that are considered low value. An intervention or a practice is low value if: is not clinically effective it can be unsafe for sub-groups of patients (or all) it is used inappropriately Procedure from the working group of the Italian Ministry of Health whose aim was to identify which interventions in oncology could be eligible in a process of disinvestment (D’Amico, 2013)

Aims To develop a simple and transparent evidence based process to identify a list of Low Value Interventions in the field of drug abuse treatment To involve drug addiction professionals in focusing on what works and what does not To contribute to an evidence-based drug policy making Both for financial and ethical issues, it is beneficial reducing or stopping health care interventions that are considered low value. An intervention or a practice is low value if: is not clinically effective it can be unsafe for sub-groups of patients (or all) it is used inappropriately Procedure from the working group of the Italian Ministry of Health whose aim was to identify which interventions in oncology could be eligible in a process of disinvestment (D’Amico, 2013)

Methods and tools A transparent and simple evidence-based process along 3 steps: a survey to identify a list of potential pharmacological and/or psychosocial treatment as LVIs for opiate, alcohol and psychostimulant dependence. Sample: PTCs and TCs professionals (Turin and Rome areas) Selection of a LVI suggested by at least 5 professionals (cut off)

Methods and tools 2. Provision of the evidence synthesis (Systematic reviews and indexed Guidelines) for each potential LVI identified PICOs tool Overlap between PICO structured LVIs and available evidence 3. A 5* expert panel (delphi technique) agrees on potential disinvestment of interventions, accordingly to provided evidence * 2 very experienced professional (H-index), 1 policy maker (public health), 1 reviewer, 1 civil society

Disinvestment proposal Operational Workflow Identified LVI Evidence? STOP NO Implication for research YES PICO Overlap? Medium/Low High Expert Panel Disagreement Agreement Disinvestment proposal

Results phase 1 Identification of potential LVIs Sample: 70 respondents (82,9% Professionals working in PTCs) Modal age group: 46-55 years Modal year of experience group: 20+ years 10 LVIs identified by more than 5 professionals List of 10 identified LVIs (>5) opiate addiciton: 2 pharmacological and 3 psychosocial stimulant addiction: 1 pharmacolgical Alcohol addiction: 3 pahrmacological and 1 pscyhosocial

Results phase 2 Evidence for clinical questions NO evidence for the clinical question “Are two drop out episodes of an inpatient treatment (TC) predictive for further drop outs?” Low/medium PICO overlap: 2 questions on alcohol 3 questions on opiates Alcohol: disulfiram for alcohol dependence treatment Job placement as social support to substain alcohol abstinence Opiates: counselling sessions alone for heroin addiction treatment BDZ for heroin detoxification Long term (18+ month) inpatient treatment

Results phase 2 Clinical questions discussed 4 clinical questions are eligible to be submitted to panel of 5 experts:

Results phase 3 Potential disinvestment Example: Do you agree on stopping GHB for alcohol detoxification? Example: Do you agree on stopping GHB for alcohol detoxification? 1 2 3 4 5 6 7 8 9 I do not agree I am uncertain I do agree The list integrated with evidence was sent to each of them. For each of the 4 interventions they had to vote whether they agreed about disinvesting and explain their decisions.

Main Results A general agreement on stopping pharmacological treatment with antidepressant for cocaine abuse was pointed out There was no substantial agreement or high uncertainty about the other clinical questions Need for further research is highlighted: Psychosocial treatment (alone v/s pharmacological) Long Term inpatient treatment (TCs) BDZ for heroin users (alone or in association) Disulfiram for alcohol addiction No agreement (mainly uncertainity) on GHB, acamprosate, detox 30 gg can be useful in some case where managed withdrawal, or detoxification, is not in itself a treatment for dependence but detoxification remains a required first step for many forms of longer-term treatment Further research for PICO’s with low overlap: disulfiram per acohol BDZ for opiate Counselling Job placement Long termCT (18+ m) Repeated inpatient treatment

Discussion This small study confirms applicability of a grass root methodology Professionals showed an high interest and motivation in being asked questions on LVIs Need for more evidence based practices Need for further research Need for more involvement of policy makers

References a.camposeragna@deplazio.it www.deplazio.net