Drug and Alcohol Findings home page in a new window EFFECTIVENESS BANK BULLETIN 11 August 2012

The entries below are our accounts of documents collected by Drug and Alcohol Findings as relevant to improving outcomes from drug or alcohol interventions in the UK. The original documents were not published by Findings; click on the Titles to obtain copies. Free reprints may also be available from the authors. If displayed, click prepared e-mail to adapt the pre-prepared e-mail message or compose your own message. The Summary is intended to convey the findings and views expressed in the document. Below may be a commentary from Drug and Alcohol Findings.


Contents


First two entries reveal that international findings on residential rehabilitation of extensive early drop-out and interlinking with non-residential services apply also to England. Next the recovery-focused Scottish drug strategy needs to show recovery in practice. Finally, how the south east of England became a test bed for 26 innovative projects to curb alcohol-related harm.

Early drop-out typical at residential therapeutic communities ...

Residential rehabilitation in England weakened by early drop-out ...

Scottish drug strategy needs to show concrete evidence of recovery ...

Lessons of test bed for alcohol harm reduction innovations ...


Effectiveness of therapeutic communities: a systematic review.

Malivert M., Fatséas M., Denis C. et al.
European Addiction Research: 2012, 18, p. 1–11
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Auriacombe at marc.auriacombe@u-bordeaux2.fr.

Methodological shortcomings in the original studies prevented this review from reaching a firm conclusion on the lasting benefits of residential therapeutic communities, though it was clear that while residents stayed, substance use was significantly reduced.

Summary Therapeutic communities are a type of drug-free residential service. Their objectives include maintaining abstinence and socially rehabilitating drug users. Unlike some other residential facilities with similar aims, in these communities the therapeutic system is based on treatment stages which afford residents increasing degrees of personal and social responsibility for the running of the service. Peer influence mediated through group processes is used to help individuals assimilate social norms and develop social skills, and social rehabilitation is promoted by daily activities. Residents have the opportunity to progress in the hierarchy to themselves managing group activities as a peer leader.

A previous systematic review found little evidence that therapeutic communities significantly improved on outcomes from other types of residential treatment, or that one type of therapeutic community was more effective than another. However, this review included services in prison or offered as an alternative to prison, possibly not comparable to those voluntary entered outside prison. It was also limited to studies which randomly allocated participants to therapeutic communities versus alternative or no treatments, and did not seek to establish which types of substance users might be best suited to therapeutic communities.

Using a similar methodology, the featured review focused on therapeutic communities for adult substance users outside the criminal justice system. Aims were to assess their effectiveness in terms of completion and retention in treatment as well as substance use, and to determine if any characteristics were associated with greater success in achieving abstinence. Studies had to report relevant outcomes and be available in English or French up to the end of January 2011, but not necessarily to have randomly allocated participants to therapeutic communities versus an alternative.

Twelve such studies were found investigating outcomes from 61 therapeutic communities and 3271 participants. All but two studies were conducted in the Americas, and in all but two cocaine was the dominant problem drug. Differences between the studies were such that it was not appropriate to combine their findings in a meta-analysis. A study which uses recognised procedures to combine quantitative results from several studies of the same or similar interventions to arrive at composite outcome scores. Usually undertaken to allow the intervention's effectiveness to be assessed with greater confidence than on the basis of the studies taken individually.

Main findings

Reported in all the studies, average retention in the communities ranged from 38 to 180 days, representing 30% of the expected programme duration. Six studies also assessed the proportion of residents who completed their programmes, ranging from 9% to 56%; 27–70% stayed at least half the expected time.

Follow-up periods during which outcomes were assessed varied from six months after entering the communities to six years after discharge. In all the studies substance use decreased during the programme or after discharge. Nevertheless, during follow-up periods, 21–100% of subjects had used substances or met criteria for relapse.

The post-discharge period was reported on in eight studies, most often (three studies and four communities) the six months after leaving. Over this period, in one study 34% of former residents had used substances in the previous 30 days, and cannabis use and drinking had both fallen significantly. In another, after staying in a community with a three-month programme, 48% of former residents had relapsed, compared to 41% when the programme was six months. Lastly, over a three-month window during the six-month follow-up, 33–41% of former residents of another community reported use of cocaine, 34–35% alcohol, 16–18% cannabis and 9–15% heroin.

The longest post-discharge follow-ups were four years in one Australian study, during which all the former residents had relapsed at least once at some time, and in Spain six years, during which 46% of former residents had relapsed, defined as substance use more than three times in two months, most commonly alcohol, cannabis and/or cocaine.

When residents dropped out, it was usually within the first month. Generally, residents dependent on heroin but not other substances were more likely than other substance users to complete treatment. Older residents and those in shorter programmes too were more likely to complete. Psychiatric disorders were unrelated to completion.

Having stayed longer in the programme was the variable most consistently associated with abstinence during follow-up periods. In one study too, communities with longer intended programmes were associated with better substance use outcomes at follow-up. In one US study, relapse was more common among patients who had been employed in the three years before starting treatment, had a history of drug injecting, or lived with a partner who also used substances. In another US study, cocaine dependence alone was more predictive of relapse than heroin combined with cocaine dependence.

In the three studies to have assessed this, after leaving 20–33% of former residents re-entered treatment of some kind during follow-up periods.

The authors' conclusions

Depending on the length of the treatment period, this review documented positive outcomes in the form of significant decreases in substance use during therapeutic community stays, though whether this was also the case after leaving was obscured by methodological issues. Most studies found low treatment completion rates, and that residents who left usually did so soon after starting the programme.

In more detail, all studies found decreased substance use during the programme and after discharge. During follow-up periods, 21–100% of subjects had used substances or met criteria for relapse and 20–33% had started another treatment episode. Longer retention best predicted abstinence at follow-up. Completion was most likely among older residents and in shorter programmes but was unrelated to psychiatric disorders.

It was clear that substance use was depressed during stays in the communities, but whether relapse continued to be prevented in the follow-up periods was unclear because of different definitions, and an inability to determine whether relapse was to the main problem drug or to another substance. These methodological limitations may explain the great variability of relapse rate across studies, casting doubt on the degree to which the results can be relied on as indicators of the benefit to be expected from such programmes.

Compared to other types of treatment, therapeutic communities do not appear to offer significant extra benefits, but might represent a better option for patients with severe psychosocial problems, depending on whether they stay long enough in the programme.


Findings logo commentary This review attempted to clarify the indecisive verdict of an earlier review by including non-randomised studies and eliminating a presumed major source of variability – whether the community was in the context of a prison or other sentencing option. Still, it too was indecisive in respect of lasting impacts, firmly concluding only that while residents stay, they use substances less often than before they entered. This in itself is a worthwhile achievement, but one considerably diluted by the review's finding that typically stays are short because residents quickly leave. This too seemed the major limitation on the effectiveness of English residential rehabilitation services in an audit of the progress of residents in 2010–11. Reporting on that audit, England's National Treatment Agency for Substance Misuse stressed that residential rehabilitation works in concert with non-residential services, typically taking its residents after they have been prepared by other services, which also continue the treatment of many residents after they leave. From the featured review it seems that internationally it is also the case that for many residential rehabilitation is not the end of a treatment and addiction career but an episode within it, making it difficult to isolate the contribution of the residential element in the treatment journey.

Findings from other reviews

Compared to the earlier review which it sought in some ways to improve on, the featured review's search for studies was very limited – to, it seems, just one database, though a major one. The earlier review found little evidence that residential therapeutic communities were, in outcome terms, preferable to residential or non-residential alternatives, a result partly due to significant shortcomings in the studies, including high proportions of participants who were not or could not be included in the analyses.

None of the randomised studies in that review addressed the issue of whether the therapeutic community model is preferable to other ways of structuring residential care outside prison. Just one of the studies directly addressed another key issue – whether residential care is critical to the success of therapeutic communities. If it is not, costs can be reduced and/or more people treated. The study capitalised on the decision in 1990 of a residential service in San Francisco to introduce a parallel day programme, also based on therapeutic community principles and scheduled to run for a year followed by aftercare. The study exemplified the main weakness of randomised trials of residential versus non-residential care: such studies must select patients who can safely and practically be sent to either option and who are willing to leave the choice to chance, yet any advantages of residential care are likely to be most apparent among homeless clients, those whose vulnerability makes non-residential care unsafe, or those with strong preferences. Given this winnowing of the caseload, not surprisingly, in San Francisco residential care conferred few long-term advantages. In the first six months (when they were at least partly protected by the residential environment) residential clients were significantly less likely to relapse, but over the next year the benefits from residential care dissipated while relapse rates among day clients remained steady. A year to a year and a half after entering treatment, about half of both groups had remained abstinent and about a quarter had for a period relapsed to using at least four times a week.

Drug and Alcohol Findings has also summarised studies comparing residential and non-residential care. From these studies it seemed that residential settings help extricate residents from particularly damaging environments but the added benefits can fade after discharge back into the community. Those who particularly benefit have been people at risk of suicide and clients with relatively severe psychiatric problems, in some cases combined with severe employment or family problems. These and other studies support the general contention that more severely dependent and problematic clients differentially benefit from residential care. Where studies have found no added benefit for more severe cases this may have been because the service's caseload was limited in severity, or because the study set severity limits so that all the subjects could safely be allocated to residential or non-residential care.

Other attributes found in some studies to favour residential care include low cognitive functioning, homelessness, low social support, and poor employment prospects. What matters in any particular situation will depend on the range of problems in the caseload and the alternative treatments on offer. For example, if very severe cases are admitted beyond the capacity of any of the options, or if the caseload is unproblematic enough to do well whatever the treatment, then none will seem preferable. Similarly, where these are available, intensive non-residential options (but not routine outpatient care) may almost match residential settings even for severe cases.

For more on residential rehabilitation see this introduction and one-click search for relevant Findings analyses.

Last revised 08 August 2012

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STUDY 2005 Addressing medical and welfare needs improves treatment retention and outcomes

STUDY 2012 Four-year outcomes from the Early Re-Intervention (ERI) experiment using recovery management checkups (RMCs)

STUDY 2012 The role of residential rehab in an integrated treatment system

STUDY 2009 The Drug Treatment Outcomes Research Study (DTORS): final outcomes report

STUDY 2003 Systematic but simple way to determine who needs residential care

STUDY 2002 For crack users, non-residential rehabilitation can match residential

STUDY 2001 Simple induction procedures help alcohol and drug users engage with residential rehabilitation

STUDY 2008 Promoting continuing care adherence among substance abusers with co-occurring psychiatric disorders following residential treatment

STUDY 2012 Randomized trial of a reentry modified therapeutic community for offenders with co-occurring disorders: crime outcomes

STUDY 2009 Results from two randomized clinical trials evaluating the impact of quarterly recovery management checkups with adult chronic substance users





The role of residential rehab in an integrated treatment system.

National Treatment Agency for Substance Misuse.
[UK] National Treatment Agency for Substance Misuse, 2012.

An audit for England's National Treatment Agency for Substance Misuse finds residential services so entwined with non-residential in the treatment careers of residents that it is not possible disaggregate their contribution; since a few months of such care costs as much as five years of non-residential care, showing value for money is critical.

Summary This is one of a series of reports from the National Treatment Agency for Substance Misuse – a special health authority which aims to improve treatment for drug problems in England – presenting a picture of this treatment based on data from the National Drug Treatment Monitoring System.

Background

Residential rehabilitation services are run by voluntary and private sector organisations, offering structured programmes which may include psychosocial interventions, individual and group therapy, education and training, and social and domestic skills. Across the wide range of types of residential rehabilitation, differing in philosophy, intensity, inclusion criteria, programme content and duration, often the only common factors are that residents stay overnight to receive treatment, and are expected to be drug and alcohol free before they start the programme.

Although locations are shifting to more local services, commitment to abstinence remains fundamental for most rehabilitation providers, placing the onus on prospective residents to be motivated to be drug-free beforehand. Sometimes detoxification is offered by the residential services themselves as the first stage of treatment; otherwise people who need detoxification are referred to NHS services first.

In 2010–11 commissioners in England planned to spend about 42 million on residential rehabilitation. Average cost per week is around 600 and stays average 13 weeks, meaning every episode costs on average about 8000. Together with preparatory detoxification and other services the figure rises to about 10,000. In contrast, the average annual unit cost of non-residential treatment for a heroin addict is about 2000. Extra cost means that residential rehabilitation accounts for 2% of treatment activity in terms of user numbers but 10% of central treatment funding.

When the National Institute for Health and Clinical Excellence (NICE) reviewed the evidence for drug treatment services in 2007, it said community services should be the frontline treatment option for most drug dependent people, but also recommended residential rehabilitation for those seeking abstinence who had significant co-morbid physical, mental health or social problems – the most complex cases.

2010–2011 audit and main findings

To clarify the role and performance of residential rehabilitation services, early in 2012 an audit was conducted of records submitted by these services to the National Drug Treatment Monitoring System. Its timing made it possible to track up to the end of March 2012 the progress of people in rehabilitation in England in the financial year from April 2010 to the end of March 2011, enabling the National Treatment Agency for Substance Misuse for the first time to provide a detailed breakdown of longer-term outcomes to which residential rehabilitation contributed.

The audit found that 4166 individuals in drug treatment in financial year 2010–2011 had been in residential rehabilitation as part of their latest treatment or (virtually) unbroken series of treatments. For three quarters (76%) this had followed non-residential treatment.

Of the 4166, 3972 were no longer in residential rehabilitation at the end of March 2012. Of these, 1880 or 45% of all residents were no longer in treatment of any kind after having been judged by their last treatment service to have overcome their dependence and no longer be in need of structured drug treatment. Most (1110) had left the treatment system direct from the residential rehabilitation service, but 770 had left after follow-on non-residential treatment.

These 1880 apparently successful treatment exits were counterbalanced by 960 former residents who dropped out of the treatment system while still considered to be in need of further help, of whom nearly half (428) did so directly from the residential rehabilitation service.

Another 1130 residents were still in the treatment system at the end of March 2012, the great majority (83%) in services other than residential rehabilitation.

Broadly speaking, the data tells us that for every ten drug users who were in treatment that year and accessed residential rehabilitation on their treatment journey:
• three successfully overcame their dependence directly from residential rehabilitation;
• one dropped out of treatment altogether;
• the remaining six received further structured support from the treatment system, of whom two went on to overcome their dependence and complete their treatment journey with a non-residential provider, two were still in the treatment system, and at least one dropped out at a later stage.

Just over a third of residents left their rehabilitation service in an unplanned way, neither having completed their programme nor been deliberately transferred to another service. However, 1013 of these 1441 former residents continued to access treatment elsewhere in the community. Usually residents left because they dropped out of or declined treatment; generally (more than 60%) this happens within the first month, often within the first fortnight.

These findings should be seen in the light of the nature of the caseload. Compared to other services, residential rehabilitation services tend to see proportionately more presentations from people who use heroin and crack – 60% of the total – and their clients are also more likely to be injecting, involved in polydrug use, or offenders. These are the most complex cases least likely to achieve a successful outcome, marked by a history of unplanned treatment episodes. However, they also have some plusses in their favour. Usually they are abstinent from drugs and alcohol, committed to becoming substance free leaving treatment, and have been assessed as capable of achieving abstinence and prepared to do so. Though residential rehabilitation tends to see people with more difficulties, these services do not usually admit highly problematic users until some preparation has already happened in the community. Often local authorities will not agree to fund people they believe are not ready for rehabilitation.

Variation between services and residents

Based on successful completions (either directly or via follow-on treatment), after attending the 'best' rehabilitation services, three quarters of residents overcame addiction, but after the 'worst', less than 10%. Of the 73 residential rehabilitation services submitting returns for more than 10 people in the year, about a dozen can claim 60% or more of their residents went on to overcome their dependence, with or without the help of other services. However, about half the residents at over half of the services do not overcome their addiction. A minority of services have success rates of 20% or less. There is no clear relationship between the outcomes achieved by providers and the complexity of their caseloads or costs of their services.

Most residential rehabilitation facilities also treat people severely dependent on alcohol. Although many fewer people are treated for alcohol dependence in England (about 110,000) than for drug problems (about 200,000), the proportion in residential rehabilitation (3%) is similar. Compared to the drug users, outcomes were consistently better for the 3881 residents who in 2010–11 spent some time in residential rehabilitation during their alcohol treatment journey. For example, compared to 28% of drug users, 38% left the treatment system directly from residential rehabilitation having been assessed as no longer dependent or in need of further structured treatment. The drop-out rate too was lower – 24% of problem drinkers versus 36% of drug users.

The authors' conclusions

The findings show that residential rehabilitation is a vital and potent component of the drug and alcohol treatment system and should continue to be so – not as an alternative to community treatment, but as one potential element of a successful recovery journey. Residential rehabilitation is integrated in the network of services that form local treatment systems. Most residents enter residential rehabilitation from other treatment services, and rehabilitation is not always an 'exit door' from the treatment system; people completing their residential treatment often require continued structured support from other parts of the system before they are ready to complete their treatment for drug or alcohol dependence. Non-residential and residential services play a significant and mutually-reinforcing role in fostering recovery, raising a question over how to assess residential rehabilitation's distinctive contribution to the drug treatment system as a whole.

The high level of early drop-out suggests that many drug users put forward for residential rehabilitation may not be ready to undertake such intensive programmes, and highlights the importance of effective preparation and robust engagement on the part of services referring people to rehabilitation and the receiving providers. Better outcomes among drinkers are possibly due to the greater personal resources they bring to the challenge of overcoming addiction, such as motivation and determination and social and family support.

Residential rehabilitation services see relatively complex cases with multiple difficulties. It seems likely that they will need to focus even more on this complex user group. With budgets under pressure, commissioners may increasingly choose to treat people in non-residential services, often as effective as more expensive residential options. But although the capacity and capability of non-residential drug treatment has improved, there remains a core of complex drug users for whom these services are not enough; it is likely be with these people that residential rehabilitation can add value in helping them towards recovery.

Providers able consistently to demonstrate they add value will find their services continue to be commissioned. Those that can't will be at risk in an unforgiving financial environment. It is apparent from this audit that some providers need to improve their performance if they are to maintain their position in the drug treatment market.


Findings logo commentary As a review of therapeutic communities found, it is hard for residential services to prove superiority to non-residential alternatives partly due to significant shortcomings in the studies, but perhaps mainly due to an inherent limitation of randomised trials of residential versus non-residential care. Such studies must select patients who can safely and practically be sent to either option and who are willing to leave the choice to chance, yet any advantages of residential care are likely to be most apparent among homeless clients, those whose vulnerability makes non-residential care unsafe, or those with strong preferences. Given this winnowing of the caseload, not surprisingly outcomes are often equivalent.

A review by Drug and Alcohol Findings of studies comparing residential and non-residential care concluded that residential settings help extricate residents from particularly damaging environments, but also that the added benefits can fade after discharge back into the resident's previous environment. Those who have particularly benefited have been people at risk of suicide and clients with relatively severe psychiatric problems, in some cases combined with severe employment or family problems, supporting the general contention that more severely dependent and problematic clients differentially benefit from residential care. Where studies have found no added benefit for more severe cases this may have been because the service's caseload was limited in severity, or because the study set severity limits so that all the subjects could safely be sent to either residential or non-residential care.

Other attributes found in some studies to favour residential care include low cognitive functioning, homelessness, low social support, and poor employment prospects. What matters in any particular situation will depend on the range of problems in the caseload and the alternative treatments on offer. For example, if very severe cases are admitted beyond the capacity of any of the options, or if the caseload is unproblematic enough to do well whatever the treatment, then none will seem preferable. Similarly, where these are available, intensive non-residential options (but not routine outpatient care) may almost match residential settings even for severe cases.

One point of contention is whether residential services should be reserved only for people shown to have been failed by non-residential (and cheaper) alternatives, or whether those keen to do so should be able to pursue their recovery through residential rehabilitation from the start. The featured report interprets recommendations from the National Institute for Clinical Excellence (NICE) as indicating that "community services should be the frontline treatment option for most drug-dependent people". In fact the experts at NICE were more definitive, saying prospective residents should "have not benefited from previous community-based psychosocial treatment". The implication is that even the highly vulnerable and multiply disadvantaged cases referred to residential services must first have tried and done poorly in non-residential options, risking life-threatening relapse and a possibly extended addiction career which could have been terminated sooner. The opposing argument is that predicting for whom non-residential care will prove inadequate is such an imprecise science that 'suck it and see' is the only realistic strategy; trying residential services first risks unnecessary expenditure which drains treatment resources.

The featured report adopts the rule of thumb that successfully completing treatment is indicative of successful treatment. For the National Treatment Agency for Substance Misuse, 'successfully completing' (1 2) means that, as reported by the treatment service from which the patient last exits, they are no longer seen as requiring structured drug treatment, and have left treatment (not just that service, but the system as a whole) no longer dependent on any illicit drug, and not using opiates or crack cocaine. They may be using other illicit drugs in a non-dependent manner and may be drinking and smoking to any degree.

The argument that successful completion is evidence of successful treatment rests partly on an analysis of patients leaving treatment for drug problems in 2005/06. Over the next four years, 57% who left having successfully completed avoided being officially recorded as problematic users of illegal drugs, neither being picked up by criminal justice system nets intended to identify problem drug users, nor returning to treatment on their own initiatives. This record of 57% seemingly staying recovered from their dependence compared with a figure of 43% among patients who left without having successfully completed treatment. The difference of 14% is appreciable, but not as large as would be expected if successful completion correlated strongly with successful treatment in terms of lasting recovery. Nevertheless it is enough to justify conclusions based on the assumption that successful completion is a better outcome than patients leaving treatment before the service considers them free of dependence and/or use of heroin or crack cocaine.

The early drop-out problem highlighted by the report may also be a feature of non-residential services offering structured rehabilitation programmes. Methadone and other opiate substitute maintenance services do not have a set programme to be completed and typically act like an on-off switch, quickly exerting an impact on crime and opiate use and often seeing a reversal when people leave. For methadone the key figure is retention time, which for about two thirds in England in 2010/11 was at least a year. The comparison between the costs of residential rehabilitation and of methadone services is made purely from the point of view of the drug service commissioner. It does not take in to account the relieving of costs elsewhere in the public sector due to the provision of accommodation and associated costs which are part of the residential package, nor any extra savings due to the virtual elimination of substance use and crime while residents remain at the centre. Nor are longer term savings taken in to account, though it is unclear whether these are greater for residential services. For example, when the DORIS study in Scotland reassessed patients 33 months after entering treatment for drug problems, whether they had initially entered residential rehabilitation or other types of services was unrelated to their employment record.

Without making any specific reservations about the featured report, it should also be borne in mind that analysts with an interest in the success of a programme they are evaluating tend to produce more positive analyses than independent analysts – in research terms, the 'allegiance effect'. In several social research areas,1 programme developers and other researchers with an interest in the programme's success have been found to record more positive findings than fully independent researchers.

1. See articles at the following web addresses:
http://dx.doi.org/10.1007/s11292-009-9071-y
http://dx.doi.org/10.1177/0193841X06287188
http://dx.doi.org/10.1093/clipsy.6.1.95
It is part of the remit of the National Treatment Agency for Substance Misuse to have an interest in the success of addiction treatment in England, to improve this, and to show this has been done by producing reports such as the featured report.

For more on residential rehabilitation see this introduction and one-click search for relevant Findings analyses.

Thanks for their comments on this entry to Rowdy Yates of the University of Stirling in Scotland. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 28 August 2012

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Top 10 most closely related documents on this site. For more try a subject or free text search

REVIEW 2012 Effectiveness of therapeutic communities: a systematic review

STUDY 2009 The Drug Treatment Outcomes Research Study (DTORS): final outcomes report

STUDY 2012 Four-year outcomes from the Early Re-Intervention (ERI) experiment using recovery management checkups (RMCs)

DOCUMENT 2013 Drug treatment in England 2012–13

STUDY 2014 Drug treatment in England 2013–14

DOCUMENT 2011 Substance misuse among young people: 2010–11

DOCUMENT 2012 Substance misuse among young people 2011–12

STUDY 2009 Results from two randomized clinical trials evaluating the impact of quarterly recovery management checkups with adult chronic substance users

STUDY 2015 Specialist substance misuse treatment for young people in England 2013–14

REVIEW 2012 New heroin-assisted treatment: Recent evidence and current practices of supervised injectable heroin treatment in Europe and beyond





Scottish Drugs Strategy Delivery Commission: first year report & recommendations to minister.

Scottish Drugs Strategy Delivery Commission.
Scottish Drugs Strategy Delivery Commission, 2011.
Unable to obtain a copy by clicking title? Try this alternative source.

In its first report an independent body established by the Scottish government to monitor its drug strategy has called for concrete evidence that recovery from addiction is being pursued and achieved at national and local levels.

Summary The Drugs Strategy Delivery Commission was established by the Scottish government in 2009 to monitor and assess whether Scotland's national drug strategy, The Road to Recovery, is being successfully implemented and achieving its aims. The commission's chair is independent of government and has the final say on its membership. Membership is voluntary through personal appointment. Service users and carers are full members. The body's programme is set annually by its members.

This report presents initial findings regarding the priority areas set for the first year: children affected by parental substance misuse; care, treatment and recovery; and the governance and accountability of the delivery system. Initial findings were discussed with the minister for community safety, and prior to publication the final report was discussed with the minister for community safety and legal affairs.

This account is based on sections of the featured document's executive summary, plus the section in the main text dealing with care, treatment and recovery.

Executive summary

Road to Recovery and delivery reform process

In 2009 following publication of The Road to Recovery, Audit Scotland Audit Scotland is a statutory body which provides services to the Auditor General for Scotland and the Accounts Commission. Together they seek to ensure that the Scottish government and public sector bodies are held to account for the proper, efficient and effective use of public funds. reported on the effectiveness of the system for delivering drug and alcohol services in Scotland. In response, the Scottish government developed a range of changes in local delivery and accountability as well as specific supports which aimed to help local systems deliver on their new objectives. These included: maintaining the ring-fencing of funding for care and treatment services; new local arrangements in the form of alcohol and drug partnerships, which aim to integrate the governance of strategic planning and delivery of services into local community planning partnerships; and newly appointed national support coordinators and an Outcomes Toolkit to help partnerships improve their effectiveness. Finally, a nationally funded Scottish Drugs Recovery Consortium was to be created to develop a national recovery philosophy and aid local systems in this change of emphasis. Creation of the independent Drug Strategy Delivery Commission would provide the Scottish government with the support of an independent expert body offering guidance, support and critical comment.

Scottish government activity 2008–2011

There has been considerable productive activity from government and within the alcohol and drug partnership delivery system since the delivery reform process concluded. Key achievements include:
• protection of ring-fenced care and treatment budgets and financial support for the partnerships;
• partnerships are now held to account through generic systems of accountability – Health improvement, Efficiency, Access Treatment (HEAT) targets for health services and Single Outcome Agreements between the national government and local community planning partnerships, setting out how each will work towards improving outcomes for local people in a way which reflects local circumstances and priorities in the context of national policy;
• national support coordinators are in post and have engaged with local alcohol and drug partnerships to develop improvement plans; and
• the Scottish Drugs Recovery Consortium has been set up, is developing its strategy, and engaging communities.

The Drug Strategy Delivery Commission too was set up and has produced its first report (the featured document), with the aim of providing an independent account of progress and advice on priorities to the Scottish government.

Notable successes have included: development of the national drug and alcohol treatment waiting time target, which has seen improved performance in terms of access to treatment and lower waiting lists; the roll out of a national naloxone programme to prevent drug overdose deaths, a response to advice from the National Forum on Drug-Related Deaths; new child protection guidance which more fully addresses the issue of children affected by parental substance misuse and the start of work to review detailed practice guidance for all practitioners working directly with children and families where substance misuse is a factor.

Improving outcomes

The Scottish government has set itself the challenging task of delivering not just investment and activity, but also improving the impact of that activity. This is best reflected through the expectation that alcohol and drug partnerships will demonstrate progress in terms of outcomes for those affected by substance use.

Care, treatment and recovery

Considerable progress has been made ( above) by the Scottish government. The commission has two major areas of remaining concern.

The first is evidencing the delivering of recovery outcomes. The Scottish government should be able to demonstrate the impact the Scottish Drugs Recovery Consortium is making in promoting the recovery of individuals, family members and communities from drug problems. At a minimum, local alcohol and drug partnerships should now be able to demonstrate early progress towards delivery of key process elements of recovery, including personalised care packages and promotion of peer support/mutual aid. Action should be prioritised to enable the assessment of progress towards recovery-focused outcomes at local and national level. This should include: inputs (evidence of recovery-orientated process such as recovery plans); outputs (evidence of improvement in performance; for example, more people progressing/accessing recovery activities such as education, training or work placements); outcomes (evidence of more people positively moving on, in or from treatment programmes and demonstrable evidence of recovery progress, such as abstinence and/or improved work prospects and better family relationships).

The second area is ensuring medical interventions are consistently high standard, reflecting the vision of The Road to Recovery. The role of primary care and general practitioners is not consistent across Scotland. National treatment standards will allow equity of delivery and a consistency of availability. UK-wide guidelines for health care professionals are an essential part of the treatment infrastructure, but urgently need to be updated to better reflect the recovery agenda and Scottish context. Development of a quality programme for medical treatments in Scotland, including the need to ensure all patients have a comprehensive assessment to determine their recovery potential, should now be prioritised. The minister should prioritise action aimed at securing the inclusion of drug and alcohol treatment as a core (General Medical Services) service for general practice patients.

Robust recovery-focused evidence is essential to underpin treatment standards. A National Evidence Group was established by the Scottish government and a review of the drugs evidence base (Research for Recovery) was commissioned and published in 2010. Further development of the evidence base and work to align research funding with the Scottish government's ambition for recovery in Scotland needs to accelerate if this activity is not to lose momentum and impact adversely on progress. Work to complete a national evidence and research strategy with clearly identified priorities should be progressed as a matter of urgency, and active links with bodies overseeing national research funding should now be explored.

Thanks for their comments on this entry in draft to Brian Kidd of the University of Dundee Medical School and NHS Tayside who chaired the Drugs Strategy Delivery Commission. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 10 August 2012

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South East Alcohol Innovation Programme: evaluation report.

Lundbeck UK Limited and Centre for Public Innovation
Lundbeck UK Limited and Centre for Public Innovation, 2011.
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In the south east of England a bidding exercise spawned a spate of short-term innovative projects to reduce alcohol-related harm, from which five models were assessed as most promising and taken forward for further implementation and assessment the following year – a rapid and intensive test bed from which others can learn as well.

Summary The South East Alcohol Innovation Programme was initiated by the Regional Alcohol Manager at the Government Office for the South East of England. From 2010 to 2011 it funded innovation activities in the public and voluntary sectors designed to reduce alcohol-related harm as measured by the level of alcohol-related hospital admissions, and to influence the adverse impact on population health and criminal justice challenges associated with violence and anti-social behaviour.

Primary care trusts (which fund public health services) and their partners were encouraged to bid for £300,000 to test out innovative approaches to meeting these objectives for between six and eight weeks. Successful bidders were encouraged to report the outcomes using a common framework.

In year one the aim was to fund as many innovative ideas as possible to tackle alcohol-related hospital admissions. In all 26 projects were funded across three thematic grant rounds:
• Seasonal alcohol campaigns;
• High impact grant programmes;
• Joint commissioner-provider pilots.

Using 'innovation funnelling', these projects were then scored against several criteria to agree which would be taken forward. The top five which had the greatest impact were selected as models for the year two bidding round, which resulted in 10 projects running between December 2010 and April 2011. The five models are described below. The projects based on these models in year two may have varied somewhat from these models.

Frequent flyers

A specialist community-based worker was appointed to work intensively with the 10 patients with the most alcohol-related repeat hospital admissions, to coordinate their care, reduce the impact on other services and ultimately reduce the likelihood of further admissions. Candidate patients were identified through medical assessment unit records and referred to the worker, who proactively contacted them and sought to engage them in a full assessment of their needs, linking with, and coordinating care and treatment from other specialist services. Offering dedicated care management was intended to achieve a more effective and coordinated approach to their treatment, freeing up the resources of those currently working with them in a more sporadic, unplanned way.

Pharmacy brief advice

The aim was to engage with staff in community pharmacies to enable them to proactively offer brief advice on alcohol to their customers. Information for pharmacy staff covered health awareness, understanding units of alcohol, early identification of possible excess, data capture on awareness and units consumed, and signposting/referral for additional support where required. This aim was to raise awareness of what constitutes safe alcohol consumption amongst low and increasing risk customers unaware of how much they are drinking.

Hostel clinical nurse

The project funded a clinician to provide clinical support and training for hostel staff to enable them to support previous rough sleepers who are dependent drinkers, with the aim of reducing their drinking and addressing attendant health problems. It extended the opportunities for alcohol-dependent residents to address their substance misuse as well as improve their mental and physical health, a group whose severe dependence and chaotic lives mean they tended not to access existing services. The project targeted drinkers for whom inpatient detoxification does not work, usually ending with a return to the hostel and resumed drinking, aiming to replace this cycle with personalised, gradual detoxification within the hostel environment.

Supported housing self-help group

Using the vehicle of alcohol workshops, the project aimed to encourage the formation of a self-help group on drinking problems in a supported housing setting, addressing some of the issues which made residents reluctant to access specialist services while raising awareness of levels of alcohol consumption and how to reduce this to safer levels. The self-help format enabled participants to support one another, drawing on their own skills and experiences. By eliciting and identifying reasons for non-engagement with treatment services, group discussions helped put in place mechanisms to manage these obstacles.

Brief intervention by hospital healthcare support workers

Healthcare support workers in accident and emergency, medical assessment unit and gastroenterology wards were trained in simple techniques to enable them to identify and briefly advise risky drinkers among the patients they came in to contact with. These workers contact all patients admitted and usually have more time than nursing and other medical staff. They were trained how to screen and advise patients while performing basic care tasks, effectively delivering information at a time of crisis for the patient in a way which it was hoped would affect their drinking and reduce repeat admissions for alcohol-related conditions.

Main findings

Based on experience in year two, identifying high impact projects through incubating, prototyping and funnelling (the year one process of promoting many innovations then selecting the most successful for further implementation) is a successful approach. Objectives to reduce alcohol-related harm and related hospital admissions are apparent across the projects. Alcohol issues acted as an impetus for innovation projects through the process of designing, developing and growing new ideas that work to meet unmet need. Despite their differences, a common message was that reduction in alcohol-related harm will only be achieved through understanding and responding to local needs and circumstances

All the high impact projects in year two have the potential to be replicated elsewhere. Projects registered outcomes relating to reductions in alcohol consumption and dependence, potential amelioration of alcohol-related health and social problems, and general improvements in health and social functioning. They showed that while increasing risk and higher risk drinkers are likely to benefit from being identified and briefly advised by generic workers in almost any setting, dependent and more chaotic drinkers may require more intensive treatment from specialist workers. A robust, flexible and diverse market serving people at risk of alcohol-related harm in all areas of provision (health, housing, social care and community settings) is most likely to generate good outcomes. However, there are some key lessons which should influence future decisions on implementation.

Projects to help people frequently admitted to hospital due to drink-related problems ('frequent flyers') have been successful. There were clear benefits in terms of client outcomes and financial savings, and the potential for replicating and scaling up and diffusion to other services. All projects which had been completed could identify a reduction in hospital-related admissions and significant financial savings could be expected based on certain assumptions. A dedicated, intensive approach was shown to yield the best results in terms of effectively engaging patients and motivating them to remain in treatment and make positive health and lifestyle changes. However, particular attention needs to be given to the setting up of these projects to ensure clear terms of reference, referral guidelines, and commitment from all the agencies involved.

At the other end of the spectrum, the project involving screening and brief advice at pharmacies showed that such interventions are effective when directed at patients drinking at increasing or higher risk levels who are typically not complaining about or seeking help for an alcohol problem. Although the project had issues in showing outcomes in the three months, it has moved forward and gained momentum locally.

Supported housing self-help group projects faced the biggest challenges, particularly in engaging and training appropriate workers and clients. Other projects had more success, in particular the hostel clinical nurse project, which helped problem drinking residents reduce drinking, significantly reduced hospital admissions, and improved access to primary health care including dentistry. Hostel staff attitudes were challenged and changed as a result of participating in the pilot. Enhanced staff skills and knowledge meant they saw the potential for positive change by working differently with residents they previously saw as unwilling to change.

A testimony to the innovation projects has been that four generated through the NHS have been adopted by the QIPP (Quality, Innovation, Productivity and Prevention) initiative, while others have been given extended funding and future planned funding on the basis of the initial outcomes.

The authors' conclusions

Recommendations based on the outcomes of the projects, the barriers they faced, and the lessons learnt, include:
• Commissioners of alcohol projects should consider using 'innovation funnelling' to identify promising local initiatives;
• As a basis for deciding which initiatives to invest in, they should also have a good understanding of the drink demography of the community for whom they are commissioning, including approximate numbers of lower risk, increasing risk, and high risk drinkers;
• Providers and commissioners should ensure significant buy-in across statutory and voluntary organisations to ensure key aims of projects are explicit in service specifications and supported to reduce and avoid duplication of service delivery;
• Providers should ensure that there are clear terms of reference for the initiative, effective project planning, and identification of resources;
• Commissioners should hold service providers to account for delivery. There should be a commitment by senior management and commissioners, particularly in the statutory sector, on staff resources for the duration of a project to avoid projects failing when staff are given alternative tasks;
• Commissioners should consider third-sector providers to deliver services to certain communities;
• Confidentiality and data protection issues should be addressed prior to commencing projects so that data to monitor progress can be accessed;
• Changes to the political landscape and funding in the statutory sector should be taken into account when first implementing projects;
• Clarity on the potential financial efficiencies expected from the interventions, how these will be defined, and how performance will be measured, should be agreed at the start;
• Consideration needs to be given to the most appropriate staff to deliver interventions and supporting delivery with ringfenced, allocated time;
• Twenty-four hour services, if judged cost effective, should be provided to enhance impact;
• Providers and commissioners need to recognise this is a difficult client group (who may have a dual diagnosis), so alcohol innovations should not be seen as an answer in isolation from other projects;
• It should be understand that alcohol intervention can have impact even when abstinence is not the end goal; a moderation goal should be considered;
• Projects receiving ongoing funded should be subject to regular review to ensure continued effective performance.


Findings logo commentary Generally it was assumed that the projects would have the desired end-results on the basis of their activities and the degree of engagement of and by clients, rather than these impacts being shown to have happened, the short duration and nature of the evaluations being such that concrete outcomes could normally not be determined. Even when they could, there was no comparison group offered no intervention or an alternative against which to benchmark the focal intervention, and projects self-assessed their performances. This means that the initiatives can only be considered promising (in some cases, very promising) in terms of achieving their aims.

From the details in a report appendix, it seems that the only model to register concrete, quantified end results was hostel clinical nurse support, one implementation of which saw dramatically reduced emergency call-outs and hospital admissions among clients who engaged with the project, resulting in substantial cost savings. There seems no reason to believe that these reductions would have happened anyway even without the nurse being there. The project was also thought to have resulted in fewer evictions, less chaotic behaviour in the hostels, and less street drinking and antisocial behaviour.

Thanks for their comments on this entry in draft to Mark Napier of the Centre for Public Innovation. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 20 August 2012

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