Towards Successful Treatment Completion A good practice guide

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Towards Successful Treatment Completion A good
practice guide

• Dr John Dunn
• Consultant Psychiatrist and NTA Clinical Team
  Leader

Effective treatment, changing lives
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Overview

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

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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

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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  their treatment is withdrawn, the client can be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
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Why are people discharged?
2006/07
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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

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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

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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

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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
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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

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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

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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
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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/compl
  etions0709.pdf

Effective treatment, changing lives