NTA, 20/11/2012

1. Medications in recovery: re-orientating drug dependence treatmentReport of the Recovery Orientated Drug Treatment Expert Group NTA, 20/11/2012

3. 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.”

4. 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

5. 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

6. 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

7. 12 immediate steps – the short version

8. 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

9. 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

10. 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

11. 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.

12. Principles and prompts – for commissioners

13. Methadone helps… and holds people…

14. 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 KDet al. (2007) Am J Psychiatry 2007; 164:797–803

15. 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.