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If a client leaves treatment before his or her treatment goals have been fully achieved or if their treatment is withdrawn, the client can be said to have had an unplanned discharge.

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Why are people discharged?

Planned discharges (44.3%): Referred on (19.4%) Treatment completed (17.0%) Treatment completed drug free (7.9%) Unplanned discharges (55.7%): Dropped out / left (32.6%) Prison (6.9%) Treatment withdrawn/ breach of contract (4.4%) Other (3.9%) Moved away (3.0%) Not known (2.3%) Treatment declined by client (0.9%) No appropriate treatment available (0.7%) Died (0.7%) Inappropriate referral (0.3%)

Planned discharges Unplanned discharges

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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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

Treatment engagement and retention

Effective treatment, changing lives

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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 OptionsInadequate 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 methadoneeffects 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 injectingstresses equipment; address social problems such as

housing if applicable

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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/completions0709.pdf

Effective treatment, changing lives