1 towards successful treatment completion a good practice guide dr john dunn consultant psychiatrist...
TRANSCRIPT
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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If a client leaves treatment before his or her treatment goals have been fully achieved or if their treatment is withdrawn, the client can be said to have had an unplanned discharge.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?
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Treatment completed drug free (7.9%) Unplanned discharges (55.7%): Dropped out / left (32.6%) Prison (6.9%) Treatment withdrawn/ breach of contract (4.4%) Other (3.9%) Moved away (3.0%) Not known (2.3%) Treatment declined by client (0.9%) No appropriate treatment available (0.7%) Died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
Effective treatment, changing lives
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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
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/completions0709.pdf
Effective treatment, changing lives