Towards Successful Treatment Completion A good practice guide

1. Towards Successful Treatment Completion A good practice guide Dr John Dunn Consultant Psychiatrist and NTA Clinical Team Leader Effective treatment, changing lives

2. Overview • Why are people discharged? • Predictors of discharge • Treatment engagement and retention • Failure to benefit from treatment • Treatment withdrawal • Completing treatment

3. Current context • 2007-08 – over 202,000 service users in drug treatment • 78% of individuals entering the treatment system were retained in treatment for at least 12 weeks and a further 4% completed treatment before 12 weeks. • Unplanned discharges have been falling from 66% of discharges in 2005-06, 58% in 2006-07 to 48% in 2007-08

4. What is an unplanned discharge? • If a client leaves treatment before his or her treatment goals have been fully achieved or if their treatment is withdrawn, the client can be said to have had an unplanned discharge. Effective treatment, changing lives

5. Why are people discharged? 2006/07

6. Predicting unplanned discharges • Service factors: wide variation between partnerships, e.g. treatment withdrawal (0% to 31%), prison (0.7% to 21%), moving away (0.5% to 14%). • Client factors: younger, male, previous treatment, self-referrals, CJ referrals, current injectors, combined opiate and crack use. • Stimulant and cannabis users – “inappropriate referral”, “no treatment available” or “declined treatment.” • Treatment withdrawal: more common in inpatient (10%) and residential rehabilitation units (16%) compared to all treatment modalities (4.5%) • Criminal justice clients: significant level of interagency drop-out • Data entry issues Effective treatment, changing lives

7. Treatment engagement and retention • Encouraging reminders • Motivational interventions • Quicker entry into treatment • Client induction • Escorting or accompanying clients to appointments • Service factors, including therapeutic alliance • Enhanced engagement strategies and assertive outreach Effective treatment, changing lives

8. Responding to clients failing to benefit from treatment • Opiate use in addition to an opioid prescription • Cocaine or crack misuse in addition to an opioid prescription • Illicit drug or alcohol use or non-compliance on inpatient or residential rehabilitation unit • Alcohol or benzodiazepine use in addition to an opioid prescription • Missing appointments or repeatedly arriving late • Missed pick-ups of medication for 3 or more days • Drop-out between agencies

9. Example – opiate use in addition to a substitute opioid prescription Problem Options Inadequate dose Dose re-assessment; increase dose Non-compliance Put client back on supervised consumption and/or more frequent pick-up Medication unsuitable Change medication regimen Reducing regimen Review treatment objectives; switch client to maintenance regimen Myths about negative Identify beliefs about effects of methadone effects of methadone and challenge erroneous beliefs Client using heroin/cocaine for “high”, Increase keywork; add psychosocial interventions (eg to reduce craving or in response to life CM), supervised consumption; provide injecting stresses equipment; address social problems such as housing if applicable Effective treatment, changing lives

10. Treatment withdrawal • 5% of all partnerships but as high as 30% • NHS zero tolerance: protecting staff vs continuing potentially life-saving treatment • NHS Security Management Service guidance • GMC guidance • Clinical Guidelines • Legal considerations • Risk assessment • Stepped approach to incidents

11. Stepped approach to incidents • Verbal warning • Written warning • Acknowledgement of responsibility agreement • Use of secure environment – Violent Patient Scheme • Civil injunction – ASBO • Criminal prosecution • Withholding treatment

12. Completing treatment • Better engagement and retention will lead to increased numbers in drug treatment in short term • Comprehensive needs assessment, care planning, delivery of effective treatment, care plan review and monitoring treatment progress and outcome are fundamental principles of treatment • Positive benefits of treatment accrue with time spent in treatment • Optimisation of effective treatment should lead to more people completing treatment and leaving services in a planned way • Social re-integration and recovery need to be further integrated into drug treatment Effective treatment, changing lives

13. Summary • The proportion of discharges that are unplanned has been steadily falling and now stands at 48% • Service factors are the most important predictors of unplanned discharges – so further improvements can be made • Engagement and retention can be improved in line with the evidence-base • Following principles of good clinical practice, service providers can deliver more effective interventions to those clients who are failing to progress in treatment • Treatment withdrawal should be a last resort and follow NHS Security Management Service recommendations • There is an expectation that as more clients achieve their treatment goals and complete treatment, they will leave drug misuse services in a planned way. • http://www.nta.nhs.uk/publications/documents/completions0709.pdf Effective treatment, changing lives