Drug Treatment Matrix cell D3: Organisational functioning; Medical treatment

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Organisational functioning; Medical treatment

Seminal and key studies on how treatment organisations affect the implementation and effectiveness of medical interventions and treatment in medical settings. Focus is on UK and US understandings of what counts as a ‘recovery-oriented’ service and on US, Australian and Canadian studies which discovered and validated elements of these visions even before they were articulated.

S Seminal studiesK Key studiesR ReviewsG Guidancemore Search for more studies

Links to other documents. Hover over for notes. Click to highlight passage referred to. Unfold extra text Unfold supplementary text

S Vision counts in US methadone maintenance clinics (1991). US clinics oriented to rehabilitation and long-term maintenance and which delivered more counselling had the best outcomes. Results later partially confirmed in a replication study (1999) of a larger set of US clinics. For discussion click and scroll down to highlighted heading.

S Abstinence-oriented ethos undermines methadone services (1995). Australian study of two clinics allocated patients purely on the basis of their home address, one oriented to abstinence, the other to indefinite maintenance. At the former this ethos led to lower doses and time-limited treatment, adversely affecting retention and substance use. For discussions click here and here and scroll down to highlighted headings.

S Ethos, dose and organisation in methadone services (Australian Government, 1995). Comparison of three Australian clinics highlights the importance of good organisation and an ethos of individualised treatment, rather than acting as a more or less efficient ‘methadone dispensary’. For discussions click here and here and scroll down to highlighted headings.

K Guideline-adherent methadone clinics do best for their patients (2008). Eight US clinics paired together in four sets for their contrasting adherence to clinical guidelines provide evidence that the relatively high dosing and intensive psychosocial services recommended in the guidelines really do make a difference. For discussion click and scroll down to highlighted heading.

K Waiting time for methadone prescribing (National Treatment Agency for Substance Misuse, 2004). British studies show rapid entry enables more referrals to engage with treatment and cuts time at risk from illegal heroin use.

K Methadone programme loosens up, increases capacity, patients do just as well (2004). Canadian study documents what happens when you ‘deregulate’ methadone prescribing and permit greater patient choice in treatment and treatment goals. Result: room for more patients, less conflict and no decrease in effectiveness. Free sources at the time of writing are linked to in the Effectiveness Bank analysis. For discussions click here and here and scroll down to highlighted headings.

K Integrated ‘chronic disease management’ model does not improve on usual primary care (2013; free source at time of wwriting). Chronic medical conditions requiring long-term behaviour change respond well to chronic disease management models based in primary care but integrated with specialised services, which support the patient in managing their illness. Expectations (2008; free source at time of writing) that the same would apply to addiction were confounded when researchers found little or no extra benefit compared to usual primary care, and no sign (2012; free source at time of writing) that increasing the quality of, or engagement with, the intervention would improve things.

K British GPs as effective as specialist methadone clinics (2003). A two-year follow-up of opiate-dependent patients sampled in 1995 by the national English NTORS study showed that experienced or supported GPs can provide methadone maintenance treatment at least as effectively as specialist clinics.

K Case management links detoxification to treatment (2006). Siting case managers at detoxification services transformed them into gateways to longer term treatment, part of a broader ‘recovery revolution’ in Philadelphia.

K Specialist and inpatient opiate detoxification improve completion rates (2000). Cost-effectiveness and cost-benefit analysis based on two UK studies, one of which showed that far more patients who choose or are randomly allocated to an inpatient setting complete detoxification, the other that the most effective inpatient setting is a specialist drug addiction ward rather than a general psychiatry ward.

K No long-term benefit from conducting opioid detoxification on an inpatient basis (2011). Randomly allocating methadone-maintained patients in Birmingham (UK) to an inpatient v. outpatient setting for their lofexidine-based detoxification may have improved completion rates, but not the low opioid-abstinence rate (16% – 11 of 68) just a month after discharge, a rate which fell to 12% five months later.

K High quality primary care helps control substance use after detoxification (2007; free source at the time of writing). The substance use of US patients (most with both drug and alcohol problems) referred to primary care after detoxification was found to be related to the general quality of primary care. Factors associated with greater problem reduction included how easy the practice makes it to get in touch and visit and whether patients sae the same doctor each time. Other findings from this study in cell B3.

K Not just a methadone patient (2013). When some Australian methadone clinics started offering treatment for hepatitis C the unexpected effect was to improve relationships with patients who felt they were no longer there just to be dosed with methadone but to be cared for as a (whole) person. Related discussion in cell B3.

R Pharmacotherapies for opioid dependence (2009). Book by leading Australian authors includes evidence on how best to organise and orient pharmacotherapies.

R Implementing evidence-based innovations ([Australian] National Centre for Education and Training on Addiction, 2008). Lessons from health promotion and medical care on how to improve addiction treatment, including the use of organisational and administrative quality-improvement strategies.

R Weak evidence for integrating addiction and mental health treatment (2013; free summary and commentary from the Centre for Reviews and Dissemination). Synthesis of research findings finds some evidence that integrated treatment for substance use and mental health problems improves psychiatric symptoms and (in residential settings) reduces drinking more than non-integrated care, but none of the slight advantages approached statistical significance. See also Effectiveness Bank hot topic on ‘dual diagnosis’. Related guidance below.


G Making recovery the paradigm for medication-based treatment ([UK] National Treatment Agency for Substance Misuse, 2012). Clinical consensus developed for UK government on how medication-based treatment for heroin addiction can be made more recovery-oriented, focusing on methadone maintenance and allied programmes. Constructed with the aid of the US recovery advocate whose work is listed below and who co-authored a commentary on the UK report. For related discussions click here and here and scroll down to highlighted headings.

G US vision of methadone maintenance as a recovery vehicle (2012). From authoritative US recovery advocate William White, a humanistic interpretation of what makes for recovery-oriented opioid maintenance, including long-term, flexible, prescribing with no pressure (but with opportunities) to reduce doses or detoxify, allied with support if wanted to develop a more satisfying and pro-social life. Based on freely available monograph (2010). For discussion click and scroll down to highlighted heading.

G NICE advises against specialist ‘dual diagnosis’ services ([UK] National Institute for Health and Care Excellence, 2016). UK’s gatekeeper to the public provision of health care says that rather than creating specialist ‘dual diagnosis’ services, health and social care (including substance misuse) services should adapt to seriously mentally ill substance users, and their care should be led by the mental health service. Other NICE guidance (2011) has dealt specifically with psychosis and substance use. Related review above. See also Effectiveness Bank hot topic on ‘dual diagnosis’.

G Getting your organisation fit to implement change ([US] Substance Abuse and Mental Health Services Administration, 2009). How to assess an organisation’s capacity to identify priorities, implement changes, evaluate progress, and sustain effective improvement programmes, and how to actually implement these changes: “If your organization is troubled, you need to build a healthier work culture before change will be possible.” For related discussion click and scroll down to highlighted heading.

G Strategies to translate theory into practice ([Australian] National Centre for Education and Training on Addiction, 2005). Chapter on organisational change includes the organisational factors which impede or promote change and how to manage them. For discussion click and scroll down to highlighted heading.

more Search for all relevant Effectiveness Bank analyses or for sub-topics go to the go to the subject search page. Also see hot topic on why some treatment services are more effective than others.

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