drug treatment monitoring and evidence based practice. a ... · 21 evidence to practice:...

Drug treatment monitoring and evidence based practice. A mechanism for improving quality and outcomes – Jon Knight & Luke Mitcheson

2

Successful completions over time in England

11,208

13,717

18,274

24,970 23,680

27,969 29,855 29,025

2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13

3

Number of adults in contact with treatment services in England

175,869

194,173

200,805

210,815 206,890

204,473

197,110 193,575

2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13

Number of adults in contact with treatment services

4

8% 9%

10%

11%

12%

13%

14%

15%

16%

Apr…

Ma…

Jun…

Jul 10

Aug…

Sep…

Oct…

Nov…

Dec…

Jan…

Feb…

Mar…

Apr…

Ma…

Jun…

Jul 11

Aug…

Sep…

Oct…

Nov…

Dec…

Jan…

Feb…

Mar…

Apr…

Ma…

Jun…

Jul 12

Aug…

Sep…

Oct…

Nov…

Dec…

Jan…

Feb…

Mar…

Apr…

Proportion of all clients successfully com

pleting treatm

ent A

pril 2010 –A

pril 2013

Proportion of opiate clients successfully completin

g treatment 2012/13

5

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

18.0%

Waltham ForestDorset

Richmond upon ThamesCornwall & Isles of Scilly

ThurrockSouth Gloucestershire

SuttonIsle of Wight

HillingdonSomerset

SuffolkWalsall

BromleyWest Sussex

StockportTamesideSt Helens

BirminghamTrafford

BlackpoolLancashire

GloucestershireBrighton and Hove

NorthumberlandPortsmouth

LutonNorth Yorkshire

WirralNationalDudleySolihull

Bath and North East SomersetWestminster

Kingston Upon HullRochdale

Hammersmith and FulhamCamden

WokinghamLambeth

DoncasterDarlingtonSouthwark

HertfordshireManchester

KnowsleyReading

Newcastle upon TyneWorcestershire

WiganBarnsley

Oxfordshire

NTDTMS data was analysed to determine what factors seemed to influencing successful completions

6

� Indicators used within the Recovery Diagnostic Toolki;�Length of time in treatment �Career Length �Previous attempts at treatment�Treatment Naïve clients �Complexity of clients �Recovery capital during treatment (including abstinence)

Nationally there has been an increase in the number of clients that are in treatment for longer

7

Opiate treatment population by length of time in treatment

32%

15%

11%

10%

7%

6%

19%

32%

14%

10%

8% 8%

6%

22%

33%

14%

9%

7% 6% 6%

24%

0%

5%

10%

15%

20%

25%

30%

35%

< 1 years 1-2 years 2-3 years 3-4 years 4-5 years 5-6 years 6 + years

2011-12 2012-13 2013-14

However opiate clients that are in treatment for shorter lengths of time have higher rates of completions

8

Opiate completion rate by length of time in treatment

11%

9%

8%

7% 7%

6%

5%

0%

2%

4%

6%

8%

10%

12%

< 1 years 1-2 years 2-3 years 3-4 years 4-5 years 5-6 years 6 + years

2013-14

Nationally there has been an increase in the proportion of clients who have been using opiates for 21 or more years

9

Opiate career length4%

8%

10%

14%

17%

16%

11%

21%

3%

7%

9%

12%

16%

17%

12%

24%

3%

5%

8%

11%

15% 17

%

14%

28%

0%

5%

10%

15%

20%

25%

30%

0-3 years 3-6 years 6-9 years 9-12 years 12-15 years 15-18 years 18-21 years 21 + years

2011-12 2012-13 2013-14

Clients that are earlier on in their opiate using career are more likely to successfully complete treatment

10

Opiate completion rate by career length

17%

13%

10%

9%

8%

7% 7%

7%

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

0-3 years 3-6 years 6-9 years 9-12 years 12-15 years15-18 years18-21 years 21 + years

2013-14

2013-14

The number of first time opiate clients has fallen over the last nine years (though is now levelling off)

11

0

10000

20000

30000

40000

50000

60000

70000

80000

90000

Prior to

2005/06

2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14

Individuals entering treatment for the first time by year of presentation

opiates

People new to treatment for the first time have better outcomes relative to those that have had previous attempts

12

Treatment naïve opiate clients - completion rates

10%9%

8%7%

19%

15%

13%

11%

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

< 1 years 1-2 years 2-3 years 3-4 years

Non-naïve opiate clients Tx naive opiate clients

With the number of treatment naïve opiate clients falling it means that there will be an increase in clients presenting to treatment that have had multiple previous attempts

13

Opiate treatment population by previous number of journeys

40%

24%

15%

9%

12%

37%

23%

15%

10%

15%

34%

22%

16%

10%

18%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

None 1 2 3 4 or more

2010-11 2011-12 2012-13

14

First time entrantsFirst time entrants

Crack useAge

Working

Ethnicity

Gender

Alcohol

Ref Source

Injecting

Opiate Use

Pregnant

Prev Tx

Other drugs

Deprivationprevalence

Postcode

The presenting characteristics of clients will greatly influence their chances of achieving recovery outcomes or not

It is possible to weight the factors that impact the achievement of outcomes

15

Not surprisingly the most complex clients have the poorest rates of completions

16

NATIONAL

Completion rates by complexity group (all clients) 12-13

46%

21%

15%

9%

5%

0%

10%

20%

30%

40%

50%

60%

Very Low Low Medium High Very High

2013-14 National distribution

2013-14 National distribution

17

4.35.0

9.210.6

9.8 10.3

0.0

2.0

4.0

6.0

8.0

10.0

12.0

0-6 months 6-12 months 12-24 months 24-36 months 36-48 months 48+ months

Ad

just

ed

od

ds

rati

o

Opiates

Length of time in treatment and likelihood of achieving a completion if not using illicit

opiates

The biggest predictor of successful completions is abstinence from opiates

18

The tool also contains outcome data on changes in drug use at 6 / 12 months

70.8%

29.9% 27.0%

3.3%

29.2%

39.8%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Using/Notusing at start

Stopped Improved Unchanged Deteriorated

8.7%

20.5%

Started using at 6 months

20.7

7.2

Mean days atstart

Mean days atreview

Change in average days use

For each indicator there is information provided wi thin the tool on:

19

� Profile and performance of different client groups� Local Authority and Treatment Agency data� Opiate / non opiate and alcohol clients� local, national and organisational comparators � Trends from the last three 12 month periods� Best practice and evidence in the form of clinical prompts

Recovery Diagnostic Toolkit Workshops• National programme of workshops delivered to regional partnerships as well

as large national providers

• Delivered by NDTMS analysis team, regional commissioners and clinical experts

• Consisted of• RDT overview

• Guidelines / evidence based practices

• Partnership and service level data

• Discussion about service changes with reference to clinical prompts

• Aim was to increase capacity in treatment system to understand their performance data better, identify key issues to fix using evidence based practices

Oxfordshire, March 14

21 Evidence to practice: Medications in recovery and The recovery diagnostic tool (RDT)

“Well-delivered OST provides a platform of stability and safety that protects people and creates the time and space for them to move forward in their personal recovery journeys. OST has an important and legitimate place within a recovery orientated system of care.”

“We need to ensure OST is the best platform it can be but focus equally on the quality, range and purposeful management of the broader package of care it sits within.”

Context: Suite of evidence-based clinical guidance 2007


2010

Medication in Recovery

• NICE guidelines

• Expert consensus on maximising positive treatment outcomes with a critical view of current practice

• OST is a highly effective intervention but need to attend to the wider treatment offer and system of delivery

23 Presentation title - edit in Header and Footer

Features of effective practice and system design from ‘Medication in Recovery’


1. Evidence based pharmacotherapy, including supervised consumption and optimal dosing

2. Robust assessment and collaborative care planning

3. Good review and adaptation of packages of care

4. Clear pathways or ‘phases’ of treatment (you can see interventions for the beginning/middle and end of a journey)

5. Different intensities of treatment are available

6. System can respond to complex need (appropriate clinical expertise, pathways and partnerships).

7. Key working is purposeful and involves low intensity psychosocial interventions

Features of effective practice and system design from ‘Medication in Recovery’8. A good range of psychosocial interventions are available.

9. Psychosocial interventions which involve families and support networks are available

10.Post treatment support and recovery check-ups are available.

11.Recovery is ‘visible ‘in the system and the exists from treatment are clear

12.The treatment system supports mutual aid

13.Workers actively facilitate access to mutual aid

14.Clinical supervision supports workers to reflect on practice and deliver techniques


Features of effective practice and system design from ‘Medication in Recovery’15.Workers have a good range of competencies, including basic, technique

and meta-competencies

16.There is strong recovery focussed culture amongst the workforce.

17.Services and workers have shared and coherent understanding of change processes

18.Organisations are effective at implementing interventions and managing change


Discuss1. Examples of these features in your services?

2. What assurance processes are in place to ensure these features of delivery are maintained / disseminated across services?

3. Any obvious gaps / issues?

4. With the knowledge of the RDT – what are the priority areas for development?


Phases of treatment: plan, review, optimise

Adaptive treatment� Plan, review, optimise (measure)

� Phases:

� Engagement and

stabilisation

� Preparation for change

� Active change

� Completion

� Layers (of intensity):

� Standard

� Enhanced

� Intensive

29Evidence to practice: Medications in recovery and The recovery diagnostic tool (RDT)

Task for the morning

Identify the key issues in your partnership data

Understand the role your team has in relation to these issues

Identify initiatives / practices to improve and maintain positive outcomes

Present this to the group for supportive and critical feedback

Partnership RDT

Identify the key issues in your partnership report

What does the report say about client outcomes?

How does this compare nationally?

What does the report say about complexity?

How does this compare nationally?

How does this picture fit with your experience in the partnership?

Team RDT

Identify the key issues in your team report

What does the report say about client outcomes?

What does the report say about complexity?

How does your team’s performance impact on the partnership outcomes?

What story does this tell you about the partnership and integrated working / pathway ?

Programme to improve outcomes

What three changes can you introduce to improve your team / partnership outcomes?

How will this work?

Opi

ate

clie

nts

usin

g fo

r 21

year

s pl

us

acro

ss S

LAM

34H

ow to

spe

ak P

HE

0%

10

%

20

%

30

%

40

%

50

%

60

%

70

%

CONSORTIUM – ASSESSMENT

AND TREATMENT TEAM –…

CONSORTIUM – CENTRAL

TEAM– LORRAINE HEWITT …

CONSORTIUM – RECOVERY

CONSORTIUM – SHARED CARE

CTRP CARE NAVIGATION

CTRP F66 TIER 3

CTRP KCA COMMUNITY

PRESCRIBING

CTRP KCA SHARED CARE

SLAM – SOUTHWARK

ASSESSMENT AND TREATMENT

SLAM BEXLEY CDT [SIGNPOST]

SLAM COMPLEX DRUG AND

ALCOHOL TEAM

SLAM CROYDON CDT

[CROYDON SUBSTANCE…

SLAM GREENWICH CDT

[BERESFORD PROJECT]

SLAM INPATIENT UNIT ACUTE

ASSESSMENT UNIT [AAU MAU

SLAM LAMBETH DRUG

INTERVENTIONS PROGRAMME

SLAM LAMBETH DTTO/DRR

SLAM LSL - INJECTING

RESEARCH STUDY-MARINA…

SLAM SIGNPOST BEXLEY

Opiate abstinence rates at six months Consortium Lorraine Hewitt House

35 How to speak PHE

81.4%

26.5% 30.1%

2.9%

18.6%

40.4%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Using/Not

using at start

Stopped Improved Unchanged Deteriorated

3.6%

15.0%

18.6%

Started using at 6 months

Opi

ate

abst

inen

ce ra

tes

acro

ss S

LAM

36H

ow to

spe

ak P

HE

0%

10

%

20

%

30

%

40

%

50

%

60

%

70

%

80

%

90

%

10

0%

CONSORTIUM –

ASSESSMENT AND …

CONSORTIUM – CENTRAL

TEAM– LORRAINE HEWITT …

CONSORTIUM – SHARED

CARE

CTRP CARE NAVIGATION

CTRP F66 TIER 3

CTRP KCA COMMUNITY

PRESCRIBING

CTRP KCA SHARED CARE

SLAM – SOUTHWARK

ASSESSMENT AND …

SLAM BEXLEY CDT

[SIGNPOST]

SLAM BEXLEY DIP

SLAM BEXLEY DTTO/DRR

SLAM COMPLEX DRUG AND

ALCOHOL TEAM

SLAM CROYDON CDT

[CROYDON SUBSTANCE…

SLAM GREENWICH CDT

[BERESFORD PROJECT]

SLAM INPATIENT UNIT

ACUTE ASSESSMENT UNIT…

SLAM LAMBETH DRUG

INTERVENTIONS…

SLAM LAMBETH DTTO/DRR

Issues: Not received sufficient “challenge” or appropriate personalised packages of care

Solutions:

• Segment …..identify those who may be ready to escalate their efforts at recovery

• Challenge: keyworkers create the therapeutic conditions and optimism for successful treatment. They can increase clients’ motivation and challenge any ambivalence towards continued drug and harmful drinking.

• Optimise: (medication, active keyworking, access to other psychosocial interventions)

• Adapt: if it isn’t working, review the care-plan and do something different

RDT Clinical Prompts - “Stuck Clients”

Issues: Pharmacological treatment not optimised, supervised consumption options not being used appropriately, low expectations of clients recovery, client issues (low strengths, high complexity)

Segment: Identify and target resources

Assessment: Why?

Make recovery visible: Peer support etc.

Challenge

Stabilisation: CM

Testing: Random testing advised

Enhanced / intense packages of care

Culture: Optimism and belief in recovery for all

RDT Clinical Prompts – “Clients still using on top of script”

Presentation to group

The key issues in my partnership are….

My teams role in relation to these issues is….

The changes we need to make in the system are….

Service changes following RDT• Staff training in MI and RP

• Distribution of “Routes to Recovery” community treatment manual

• Introduction of competency assessment of RP / MI skills to be used in supervision by team leaders

• Team leader training

• Nurse responsible for induction and dose titration at start of pathway

• Targeted package of enhanced psychosocial interventions for clients using heroin / cocaine (includes contingency management) post 4 weeks

• Team reports / client level data: TOP data is used to identify clients still using heroin. Care plans are scrutinised.

NDTMS developmentsEvidence based Interventions plus outcome data

Can begin to ask questions about the use of the interventions (or at least the reporting of them) and link these to outcomes in the RDT


drug treatment monitoring and evidence based practice. a ... · 21 evidence to practice:...

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