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Therapeutic communities for addictions in Europe: available evidence and future challenges

Therapeutic communities for addictions in Europe: available evidence and future challenges. Prof. Dr. Wouter Vanderplasschen Ghent University, Belgium Department of Orthopedagogics Wouter.Vanderplasschen@UGent.be. Overview. Background of the study Introduction Objectives Methods

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Therapeutic communities for addictions in Europe: available evidence and future challenges

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  1. Therapeuticcommunities for addictions in Europe: availableevidence and futurechallenges Prof. Dr. Wouter Vanderplasschen Ghent University, Belgium Department of Orthopedagogics Wouter.Vanderplasschen@UGent.be

  2. Overview • Background of the study • Introduction • Objectives • Methods • Results • TCs in Europe today • Overview of included studies • Studyfindings • Conclusions

  3. 1. Background • Studycommissionedby the EMCDDA (European Monitoring Centre for Drugs and Drug Addiction) • Research period: October 2011 – August 2012 • Launchpublication: January 2014

  4. EMCDDA Insights Series

  5. 2. Introduction • Drug-free TCs: • long history (since 1958) + model for manyresidentialTx programs • Definition: • “a drug-free environment in which people with addictive problems live together in an organized and structured way to promote change toward a drug-free life in the outside society” (Broekaert, Kooyman & Ottenberg, 1998, p. 595). • Many variations, not necessarily residential

  6. The rise of TCs in Europe • Implemented in Europe in late 1960s - early 1970s • Adaptation of the behaviorist American model to European culture and treatment traditions (e.g. milieu therapy, psycho-analysis) • Quickly spread across Europe (1980s) • Differencesbetween Western and Eastern Europe • Predominant treatment model until: • Spread of the HIV/AIDS epidemic • Expansion of MMT and harmreduction

  7. TCsunderpressure • Anno 2012, TCs are challenged for: • High costs of lengthy treatment period • Lack of evidenceresultingfromsystematic reviews (Smith et al., 2006; Malivert et al., 2012) • Low coveragerate of drug addicts • High drop-out and relapse rates • Changing views on addiction • Alteredclientexpectations, socialnorms and theoreticalinsightsregardinglengthystays in closedcommunities • Situationvariesacross Europe: • eg. North vs. South and East Europe • ModifiedTCs for specificpopulations, shorter term programs and smaller scale units

  8. TC research • TCswidelyevaluated • Early reviews underscored the strong relationshipbetween TIP and success • Abstinence : 85-90% amonggraduates vs. 25-40% amongearly drop-outs (Holland, 1983) • Applicability of controlledstudy design in TC environments? • Lack of adequate control conditions • High attritionrates • Reciprocalinfluence of resident and TC environment • Most studies from US, and few and mostlyuncontrolled TC-studies from Europe • Need for a systematic and comprehensive review of availableevidencefrom European longitudinal studies + fromcontrolled studies

  9. Rationale and aims of the EMCDDA-publication • Practices in European TCs + population profiles and outcomes are hardly documented • Renewed interest in recovery and drug-free treatment due to the losses of harm reduction, devastating influence of drugs on the developing brain and limitations of pharmacological Tx • Objectives of the Insights Publication: • Characterize recovery-oriented treatment in Europe and identify recent evolutions and future directions • Review TC effectiveness with a scope on studies performed in Europe • Propose guidelines and recommendations for future development of TC-treatment, based on a comparative study across EU-countries

  10. 3. Objectives • Identify the number of TCs in Europe and theircapacity + availability of TC treatment across EU • Review the evidencefrom European longitudinal studies on TCs, as field effectiveness studies reflect ‘real life Tx’ (DeLeon, 2010) + more commonalitiesbetween European TCsthanwith American counterparts (cf. Goethals et al., 2010) • Toimprove the visibility and accessibility on European TC research

  11. 4.1. Methods • Identification of keyinformants/country (EFTC, EMCDDA focal points, TC experts, country reports, …) • Three corequestions: • 1. What is the number of addiction TCs in [Member State]? ... TCs • 2. What is the total capacity (number of beds) of these TCs? ... beds • 3. What is the total number of residents in these TCs per year? ... Residents • Missing information for Germany and Croatia • Sources of bias: conceptual discussions (‘unofficial TCs’), ≠ health care systems, accuracy of registration and reporting (2011), changes in # persons treated/year

  12. 5.1. TCs in Europe today

  13. Note : a= 2010 data ; b = 2009 data ; c = 2008 data ; n.a. = not available

  14. Mainfindings • Spread all over the EU (except Croatia, Turkey) • N=1200, but 2/3 in Italy • Low number of TCs (<5) in manycountries (Denmark, Latvia, Romania, Sweden), but more established in South (Greece, Italy, Spain, Portugal) andEastern Europe (Hungary, Lithuania, Poland) • Challenges: closedown of TCs, reduction of Txlengthandnumber of beds • Estimation of number of TC beds in EU: 15 000

  15. Mainfindings • Varyingcapacity (15-25/TC), but higher in somecountries (Cyprus, France, Poland, UK) • Averagenumber of TC-residents/year: indication of client turnover + Txlength • Variesfrom 3 to 18 months, usuallybetween 6 and 12 months • 2:1, but higher in somecountries (Poland, Finland) andlower in othercountries (Belgium, Ireland, Cyprus) • Number of TCs/capita: • Italy, Malta: > 1 TC per 100 000/inhabitants • Mostly :1 - 2 TCs per 1 000 000/inhabitants; higher in Lithuania, Portugal, Slovakia andlower in Denmark, France, Sweden and UK • Cave! lack of standardized data collectionmethods

  16. 4.2 Methods (eligibility criteria) • Eligibility criteria • Intervention: Drug-free TCs for the treatment of drug addiction • Target population: Adults addicted to illegal drugs • At least one of the following outcome measures was reported: • substance use (illicit drug use, alcohol use, …) • length of stay in Tx(retention, treatment completion/drop-out) • employment status • criminal involvement • health and well-being • family relations • quality of life • treatment status • mortality • …

  17. 4.2. Methods (eligibility criteria) • Type of studies: ‘Field effectiveness’ studies • Studies that examined the effectiveness of TC treatment in a single or multi-program study using follow-up (outcome) assessments after treatment • Studies including a comparison of various treatment modalities (e.g. NTORS, DTORS, DORIS, VEDETTE) needed to report findings on TC treatment separately from findings regarding other types of (residential) treatment • Selection restricted to Europe, including non-EU-countries like Norway and Switzerland. • Language: English, Dutch, French, German, or Spanish • Data reported in adequate format: pre- and post-measurement

  18. 4.2. Methods (search strategy) • Databases search (up to December 31st, 2011 ): • ISI Web of Knowledge (WoS) • PubMed • DrugScope • No language or publication year restrictions. • Key words : “therapeutic communit*” AND “drug* or addict* or dependen* or substance use” AND “outcome* or evaluation or follow-up or effectiveness” • Reference lists of retrieved studies and available reviews • The International Journal of Therapeutic Communities

  19. 5.2. Overview of included studies (n=20)

  20. Overview of included studies (n=20)

  21. Overview of included studies (n=20)

  22. Overview of included studies (n=20)

  23. 5.3. Studyfindings

  24. Outcomes ‘field effectiveness’ studies • 20 studies withlongitudinal design and post-Txevaluation (14 unique studies) • Spain (n=3), UK (n=3), Norway (n=2), Italy (n=2) the Netherlands (n=2), Germany (n=1), and Switzerland (n=1); ongoing studies in Czech Republic and Poland • Published between 1977 and 2012 (8 since 2000) • No separate data reported on TCs in large Tx outcome studies • No studies on modified TCs

  25. Outcomes ‘field effectiveness’ studies (2) • Sign. improvementsbetween baseline and post-treatment assesments • Positiveoutcomesmostlyrelatedtosubstanceuse, employmentandsocialfunctioning • TC outcomes superior tothose in othersettings (Kooyman, 1992; Uchtenhagen, 1987) • Notallresidents benefit equallyfrom TC Tx: 60% improved, 30% unchangedand 10% deterioriated (Van de Velde, 1998; Lopez-Goni, 2010) • Mortalityrates: 7-12% (Berg et al., 2003; Wilson, 1985)

  26. Outcomes ‘field effectiveness’ studies (3) • TC effectivenessrelatedtolength of stay in Tx • Drop-out high, particularlyduring first months • 27-30% relapses during first monthafterleaving the TC • Completionrates(around 20%) varybetween studies + depending on program length • TC completers vs. drop-outs: superior outcomes on alloutcomemeasuresafter 15 and 60 months (exceptemployment) (Lopez-Goni et al., 2010; Fernandez-Montalvo et al., 2008)

  27. Outcomes ‘field effectiveness’ studies (4) • Successrates (abstinence!) varybetween 20 and 55% • Fernandez-Montalvo et al., 2008: 44,5% positive overall state of functioning • Fredersdorf, 2000: 55% sociallyintegrated • 20-30% in studies thatincludedall ‘entrees’ + high follow-up rates • Relapse rates: 40-50% (range 22-80%), associatedwithothernegativeoutcomes • relapse becomeslesslikelyafter 5 years (Quercioli et al., 2006) • High levels of alcohol useamongformer TC residents! • Cave: sampling methods, attritionrates,

  28. Outcomes ‘field effectiveness’ studies (5) • Less focus on criminalinvolvement • Reduction of legalproblems + fewer re-arrestsandreincarcerations • Most studies report improvedemploymentandeducationalachievements • LOS and program completionassociatedwithbetterabstinenceandreconvictionrates • Positiverole of parentalinvolvement + participation in AA/NA immediatelyafterTx

  29. 6. Conclusions • Unequal spread of TCsand TC research across Europe • exploreavailabledata + developmulti-site studies • Needfor studies witha soliddesign • Treatment retention, andcompletion, associatedwithbetteroutcomes • ClinicalandanekdotalevidencethatTCsproduce change • TC treatment noteffectiveforall types of substanceabusers • It works, but why does itworkandforwhom in what stage of the recovery process? • Needforevaluation of cost-effectiveness in European TCs • Narrative review does notallowtoweighfindingsfrom different studies nor toestimate effect sizes • Needfor recovery-orientedapproach • Gainmore active control over theirlives (‘agency’) • A way of living a satisfying, hopefulandcontributing life, even with the limitationcausedbyillness (Slade et al., 2008) • Importance of subjectivequality of life + individuals’ strengthsand support systems

  30. Conclusions • FutureforTCs: ‘niche marketing’ • Addressvulnerablepopulations • In prison anddetentioncentres • Urgeforcloser cooperation betweenabstinence-orientedandharmreduction services • Needforongoing support andcontinuing care • Increasingimportance of outreachandcommunity-basedservices • Maintain changes made duringresidentialstay • Role of recovered drug users • ProtectTCsfromdangers inherent to the system andinsurequality of care • Adherenceto TC standardsand goals • Training andcontinuingformation

  31. Acknowledgements • Thanksto: TeodoraGroshkova (EMCDDA), Rowdy Yates (EFTC), George De Leon, Stijn Vandevelde, allkeyinformantsandmanyothers • Publicationwillbelaunchedearly 2014 • Tobeinformedaboutpublicationlaunch: • Wouter.Vanderplasschen@UGent.be • www.orthopedagogiek.ugent.be

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