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Do ‘wrap-around’ services help or hinder addiction treatment?

In the UK it seems unclear whether treatment services will be forced to narrow down to substance-focused objectives to cut costs, or flower in to holistic providers of (or gateways to) the constellation of services (‘wrap-around care’) which seem demanded by reintegration and recovery agendas, such as those specified in Scottish guidance which called for addiction treatment patients to have access to a full range of psychological and psychiatric services and services addressing employability and accommodation. In England a survey of treatment services conducted in 2014 suggested that funding constraints had on balance led both to a cutback in core services and the retraction of health, employment and education provision, though some services felt their provision had actually improved. If national policy aspires to holistic recovery, the ambitions of patients too are not narrowly substance-focused. When asked, the accounts of patients like those on methadone in Belgium of what for them constitutes a good quality of life are no different from those of the general population: satisfying social relationships; psychological well-being; an occupation; being independent; and a meaningful life.

For the Effectiveness Bank, the main issue is – does the degree to which treatment services provide or organise wrap-around care really make a difference? Given the typically multiple and severe problems of public service treatment caseloads, it seems obvious that a holistic approach would help get patients back on stable recovery feet, but it is also possible that organising wrap-around care would detract from the core addiction treatment mission. The most comprehensive test of which side the evidence falls was funded by the US government’s drug misuse agency. Analysts amalgamated relevant studies to test the agency’s assertion that “Effective treatment attends to multiple needs of the individual, not just his or her drug abuse,” including any associated medical, psychological, social, vocational, and legal problems. Because most studies did not assess whether clients’ needs were actually addressed, instead for each study the analysts calculated how many more of specified ‘ancillary’ services were provided to patients offered the focal treatments addressed by the studies than to those in the comparison groups. The greater this number, the greater the scope for patients in the focal treatments to receive extra services matched to their needs. Over 236 such comparisons, each additional service was associated with a small but statistically significant further reduction in drug use.

A more nuanced approach would be to offer extra services only to patients who need them. In a major US study, for patients most in need of ancillary services – in particular vocational and housing aid – receiving this help also helped them control their illegal drug use. A more stringent test was conducted in Philadelphia, where the directors of four private drug and alcohol services were asked to provide at least three professional vocational, family or psychiatric services to randomly selected clients with severe problems in these areas. Other clients with such needs received standard treatment. For these employed, privately insured patients, systematising responsiveness to need in this way improved treatment retention and completion rates and six-month outcomes in the targeted areas, as well as reducing arrests and the need for further treatment. This was a particularly stringent test because there was nothing stopping the other clients also receiving these services (which were available from agency staff on-site) and many did, but to a lesser degree. However, the researchers cautioned against generalising their findings to other groups.

The alternative of across-the-board service provision rather than matching to needs risks being wasteful. Among the most widely cited of addiction treatment studies is the classic 1999 trial at US methadone services which suggested that modestly increasing availability of counselling buys more abstinence per dollar than universally offering more frequent daily access plus other services.

If targeting extra services to patients in need is the cost-effective option, the next issue is how to construct services which routinely find out what their clients need, and routinely respond to these assessments by providing appropriate services. Most revealing is a study of US services where, as perhaps for many in Britain, intake assessments of patient needs were largely redundant paperwork which led nowhere in terms of meeting those needs. Linking those assessments to a computerised guide to local welfare and medical services transformed them into a practical route to the obtaining services matched to needs – and treatment completion rates doubled.

A more elaborate and extended version of a needs-services matching system has been trialled in California. This carefully worked out strategy also offers an unusually fully developed model for promoting recovery and judging the outcomes achieved by a service in the light of its patient profile.

What you will not find in the Effectiveness Bank entries retrieved by this search is also relevant. Notably missing are the 2012 UK expert guidelines on drug-based treatments for addiction. Though explicitly about re-orienting services to recovery, they perhaps realistically emphasised a division of labour which saw treatment services focusing on addiction treatment, and liaising with other services to help patients with needs such as relationships, work, life skills, and housing. The perennial problem is how to ensure access to those services when they are not provided on-site at/by the addiction treatment service. At least in the US context, offering transport to external services can be critical.

Last revised 29 April 2015. First uploaded 01 September 2011

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